Health Screen & Consent
Thank you for your interest in our Pilates Classes. As Chartered Physiotherapists we are required to assess the suitability of our online Pilates classes for each individual. All information is treated as confidential & in line with GDPR regulations. We may need contact you via email or telephone to discuss any concerns. Please complete the following short questionnaire:
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Email
*
Phone Number
-
Area Code
Phone Number
Mobile Phone Number
Date of Birth
*
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Address
Street Address
Street Address Line 2
City
State / Province
Post Code
Height if known
Weight if known
What are the main reasons you are interested joining our ChiPhysio Pilates Facebook Group?
*
Cardiovascular Protection
Manage aches & pains
Impove flexibility
Improve Posture
Improve strength
Access to physio support & advice
Help with routine
Help with morale
How do you rate your current level of health (On a scale of 1-10, where one is extremely poor & 10 is excellent)
*
Please list any medications you are currently taking (e.g. warfarin)
Do any of the following apply to you :
Arthritis
Asthma
Autoimmune Disorders (e.g. lupus, rheumatoid arthritis)
Cancer
Dementia / Alzeihmers
Depression
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Low Blood Pressure
Mental Illness
Muscular Dystrophy
Obesity
Osteoporosis
Major surgery
Skin Disorders
Strokes
Thyroid Over Active
Thyroid Under Active
Pregnancy or breastfeeding
Given birth within last year
Ever taken oral steroids?
Other
If you ticked any of the above please give details:
Do you you usually do any regular exercise, if so what type?
Frequency of exercise (days per week):
*
6 - 7
3 - 5
1 - 2
0
Many of our exercises involve lying on a mat, small cushions can be used to make positions more comfortable, tick the positions you can exercise in:
*
Lying on you back
Side lying on left & right
Lying face down
Kneeling on all fours
Please agree to the following
*
I will keep ChiPhysio Pilates informed of any changes to my health
Please agree to the following
*
I will watch the Induction videos & exercise with respect to precautions outlined.
Thank you for completing this form. Finally, how did you hear about ChiPhysio Pilates Online?
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