Pre-Exercise Form

Pre-Exercise Form

Please answer the questions below as accurately as you can. All your answers will be treated in the strictest confidence. Thank you for your time to do this.
Name*

First NameLast Name
Email*
example@example.com
Home Phone Number*

Area CodePhone Number
Mobile Number*

Area CodePhone Number
Address*

House Name/Number

Street Address Line 1

CityCounty

Post Code
Occupation*
Type of occupation
Age*
Name of contact in case of accident*
Phone Number for contact in case of accident*

Area CodePhone Number
Sex*

MaleFemaleOther
Are you a newcomer to exercise?*

YesNo
Are you active on a regular basis?*

YesNo
If, YES, what type of regular physical activity have you done in the last 3 months, e.g. sport, dancing, walking, gardening, swimming, Pilates?
Frequency of Exercise

1 - 2 times a week3 - 5 times a week6 or more times a week
Have you suffered from*

Heart diseaseAnginaStroke in the last yearHigh or low blood pressureAny cardio-vascular problemChest painsFeeling faint or dizzy spellsAsthma or shortness of breathHeadaches or MigrainesAre pregnant or had a baby in the last 6 months?None
If you have ticked any of the above, please add any additional information below AND you are advised to check with a medical practitioner before stating the course.
Do you suffer with*

Arthritis - Osteo or RheumatoidOsteoporosisAsthmaCrampsDiabetesNone
If you have ticked any of the above, please add any additional information below...
Do you have any injuries which you think may limit your ability to exercise?*

NeckShouldersBackHipsKneesAnklesPersistant back acheCartilage troubleMuscular painPelvic floor issuesNo
If you have ticked any of the above, please give details...
Have you had any surgery*

YesNo
If, YES, please give details of what & when...
Do you have*

Sight impairmentHearing impairmentNone
Are you taking any ...*

MedicationSupplementsNone
If you have ticked any "Are you taking any..." from above, please give details of the medication and what it is for. Thank you...
Do you smoke?*

YesNo
Are you dieting/fasting*

YesNo
The above health responses given are reflective of my current status. I agree to inform Pilates with Esther and my instructor, if there are any changes in my health status due to injury, illness or otherwise. I will consult with my doctor and not partake in the class until I have been advised by my doctor, that it is safe for me to do so. I acknowledge that there are inherent risks in taking physical exercise and that I know of no medical reason why I should not undertake a Pilates/Fitness exercise programme. I also agree to comply with any verbal instructions from the instructor regarding health and safety whilst doing the class at home or face to face.
I have read the statement above and will comply to the best of my knowledge*

Yes
I give my consent for Pilates with Esther to hold my contact details and health screening data and use them to send me class information/newsletters when appropriate.
I have read the statement above and consent to this*

Yes
I give permission for my image to be used in photos and video recordings that may be used on social media platforms for advertising classes run by Esther Fransham and Pilates with Esther. I won't be doing close ups, just more general shots.
I have read the statement above and give permission for my image to be used*

YesNo
Your Signature*
Date signed*

DayMonthYear
Date
Please verify that you are human*
Should be Empty: