Pilates Screening Form

PERSONAL DETAILS

Full Name

First NameLast Name

DOB

DayMonthYear

Phone Number

Area CodePhone Number

E-mail

example@example.com

Address (mandatory for private clients)

Full Address

(continue)

CityCountry

Post Code

EXERCISE BACKGROUND, GOALS AND OBJECTIVES

Have you been exercising recently? Please check all options

If checked any option above, please describe frequency and how long have you been doing the activity

What do you think you are not able to do and you believe you should be able to? Any activity, as gardening, sitting for long, dressing up, running, carrying weight... Also what are your goals?

MEDICAL HISTORY

Do you have any of the conditions below? Please check the boxes as appropriated

If checked any of the boxes above, please detail the informations below

Check the symptoms or conditions that you're currently experiencing:

If checked any of the boxes above, please detail the informations below

Are you currently taking any prescribed medication? If YES, please describe

Have you had any injuries, conditions or surgeries in the past? If YES, please describe

Are you currently been treated for any injuries or conditions? If YES, please describe

Have you had any knee, hip or limb replacement? If YES, please describe

Do you current have any undiagnosed pain? If YES, please describe

Do you have any movement limitation? If YES, please describe

Please read each of the following question and answer YES or NO

Has your doctor ever said you have a heart condition and you should only do physical activities recommended by a doctor?

Do you feel pain on your chest when you do physical activities?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Is your doctor current prescribing medication for blood pressure or heart condition?

Do you know any other reason why you should not do physical activities?

If you said YES to any of the questions above you need to obtain doctor's clearance priory to undertaking any Pilates exercises. Do you have doctor's clearance to undertake Pilates exercises? Yes or No

FEMALE ONLY

Are you pregnant or given birth within the last 12 months?

If YES on the question above, have you been given a letter of clearance from you GP/Obstetrician?

Please outline what trimester you are in, number of weeks along, information about the birth, abdominal separation or any other information your Pilates instructor should be aware of:

AGREMMENT

I hereby confirm that the information I have provided in this document is accurate and complete to the best of my knowledge. I acknowledge that I have understood and responded fully to the pre-exercise screening form. I also recognize that it is my responsibility to notify AS Pilates of any changes to the information provided above.
I voluntarily choose to participate in the exercise sessions and understand that, like any exercise program, there is a potential risk of injury. This applies to all formats offered by AS Pilates, including Online Sessions, Private Sessions, In-Person Group Mat Classes, and Studio Sessions.
I acknowledge that AS Pilates does not offer refunds for cancellations. For group sessions, I understand that if I am unable to attend a prepaid session and notify AS Pilates at least 48 hours prior to the class start time, I will have the option to:

1. Attend another class within 6 days of the cancelled session, subject to availability; or

2. Receive a link to a pre-recorded online session, available for 7 days.

For private sessions, I understand that if I cancel more than 48 hours before the session, I may reschedule. However, if I cancel within 48 hours of the session, I forfeit the session, and no refund or rescheduling will be provided.

I understand that the Andreia Silveira de Souza is a Comprehensive Polestar Pilates instructor fully qualified to work in UK and worldwide.

I agree with the term above

The sessions might be recorded for studying proposals or advertising. If you do not want to be part of the picture/video used for advertising please select NO below.