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 Name Last Name
Email *
example@example.com
Home Phone Number *

Area Code Phone Number
Mobile Number *

Area Code Phone Number
Address *

House Name/Number

Street Address Line 1

City County

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

Area Code Phone Number
Sex *

Male Female Other
Are you a newcomer to exercise? *

Yes No
Are you active on a regular basis? *

Yes No
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 week 3 - 5 times a week 6 or more times a week
Have you suffered from *

Heart disease Angina Stroke in the last year High or low blood pressure Any cardio-vascular problem Chest pains Feeling faint or dizzy spells Asthma or shortness of breath Headaches or Migraines Are 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 Rheumatoid Osteoporosis Asthma Cramps Diabetes None
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? *

Neck Shoulders Back Hips Knees Ankles Persistant back ache Cartilage trouble Muscular pain Pelvic floor issues No
If you have ticked any of the above, please give details...
Have you had any surgery *

Yes No
If, YES, please give details of what & when...
Do you have *

Sight impairment Hearing impairment None
Are you taking any ... *

Medication Supplements None
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? *

Yes No
Are you dieting/fasting *

Yes No
Have you had COVID-19? This will have been diagnosed by your health professional. *

Yes No
If Yes, when?
If you said, Yes, to having COVID have you experienced what you consider to be any signs or symptoms of Long-COVID?
If not, have you noticed any changes to your normal level of energy, physical activity or exercise that has been altered or seems to be worsened since your exposure to the virus?
Have you had the COVID-19 vaccine? *

Yes No
If Yes, when?
Have you had one jab or two? Please include dates.
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 *

Yes No
Your Signature *

Clear
Date signed *

Day Month Year
Date
Please verify that you are human *
Should be Empty:

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