The Pilates Corner New Member PAR-Q

Name*

Phone number*

Email Address*

Address*

City

Post Code

Occupation*

Date of Birth*

If you are planning to take part in a class with us and you are new to this form of exercise, start by answering the questions below. If you are over 69 years of age, and you are not used to being very active, please check with your doctor before attending your first session.

Have you done any Pilates before?*

NeverI have attended classes in the last monthI have attended just a couple of classes beforeI used to attend regularly but not in the last 6 monthsI have not attended class in the last 12 monthsOther

Do you do any other forms of exercise or sports regularly? If so what?

Does your job involve any of the following (please tick)

Any other repetitive action, please specify

Do you ever have spells of dizziness or feel faint?*

YesNo

Do you ever have spells of dizziness or feel faint?*

YesNo

Has your Doctor ever said that you have any sort of heart trouble or defect?*

YesNo

Have you ever had either high or low blood pressure, and/or high cholesterol level?*

YesNo

Have you ever had either high or low blood pressure, and/or high cholesterol level? Please tick all that apply*

High Blood PressureLow Blood PressureHigh CholesterolNone

Have you ever had Asthma, Chronic Bronchitis or any other chest ailments?*

AsthmaChronic BronchitisNoneOther

Do you suffer from severe headaches or migraines?*

YesNo

If you answered YES to any of the above questions, please give details

Have you had major surgery in the last 10 years?*

YesNo

If yes, please give details.

Have you had minor surgery in the last 2 years?*

YesNo

If yes, please give details.

Have you ever been told that you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that may affect your ability to exercise?*

YesNo

If yes, please give details.

Do you have neck or back pain?*

YesNo

If yes, please give details.

Do you have pain or restricted movement in any other joints? (E.g. hip, knee, ankle, shoulder).*

YesNo

If yes, please give details.

Are there any movements or positions which cause you pain?*

YesNo

If yes, please give details

Is there anything else in your medical history that you feel could affect your ability to exercise?*

YesNo

If yes, please give details.

Are you taking any medications that may affect your ability to exercise?*

YesNo

If yes, please give details.

Are you currently seeing a Physio/Osteo/Chiropractor or similar therapist?*

YesNo

If yes, do you give permission for us to contact them? (Please give name and contact details if so).

(Women only) Are you pregnant or have you had a baby in the last 5 years? (please give details of any babies born in the last 5 years.

Not PregnantPregnantHad a baby in last 5 years

If you are currently pregnant or have given birth in the last 12 months we require you to complete our Pregancy & Post-natal Health Questionnaire. This can be done in place of this form.

Pregnancy & Post-natal Health Questionnaire

If pregnant, please tell us your due date

Date

Baby #1 DOB

Date

Baby #2 DOB

Date

Baby #3 DOB

Date

Baby #4 DOB

Date

It is important that you advise us before commencing any session if, for any reason, your health or ability to exercise changes.

Pilates is a very safe form of exercise, however as with all forms of exercise it is prudent to consult your doctor if you suffer from any health problems or special conditions, or if you are in any doubt as to its suitability. If you are undergoing any medical treatment or are taking medication, you will need to consult your medical practitioner first. Pilates should not be considered a replacement for professional medical counselling or treatment.

Exercise should be performed at a pace which feels comfortable for you. PAIN is the body's warning system and should NOT BE IGNORED. You must take responsibility for your own body during each Pilates session and must inform the instructor if you feel any discomfort. Please also inform the instructor if you felt any discomfort after a previous session. The instructor can accept no liability related to the participation of the class if: 1) The doctor has advised you against such exercise. 2) You do not act responsibly with your body or fail to observe instruction on safety or technique. 3) Such injury is caused by the negligence of another participant in the session/studio.

I understand that The Pilates Corner instructors use hands-on correction and I hereby consent for my instructor to work in this way. I understand that I will be charged for my class if I do not give 12 hours' notice of cancellation. (24 hours for 1:1 and small group sessions).

I confirm that I have read and understood the above advice and that the information I have given here is correct.

Signed*

Date*

How did you hear about The Pilates Corner*

Name of friend that referred you so we can thank them.

If you had a flyer, please let us know where the flyer came from

I am happy to receive information and offers from The Pilates Corner and Pilates with Emma.*

Yes, I'm happy to be contacted.Text onlyEmail onlyNo contact