ChiPhysio Pilates Classes Subscription and Online Health Screen

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 NameLast Name
Gender*

MaleFemale
Email *
Phone Number

Area CodePhone Number
Mobile Phone Number
Date of Birth*

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Height if known
Weight if known
What are the main reasons you are interested joining our ChiPhysio Pilates Facebook Group?*

Cardiovascular ProtectionManage aches & painsImpove flexibilityImprove PostureImprove strengthAccess to physio support & adviceHelp with routineHelp 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 :

ArthritisAsthmaAutoimmune Disorders (e.g. lupus, rheumatoid arthritis)CancerDementia / AlzeihmersDepressionDiabetesHeart AttackHigh Blood PressureHigh CholesterolLow Blood PressureMental IllnessMuscular DystrophyObesityOsteoporosisMajor surgerySkin DisordersStrokesThyroid Over ActiveThyroid Under ActivePregnancy or breastfeedingGiven birth within last yearEver 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 - 73 - 51 - 20
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 backSide lying on left & rightLying face downKneeling 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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Health Screen & Consent