Pilates/PT Informed Consent Form

Pilates/PT Informed Consent Form
Personal Data
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Age
Gender

MaleFemale
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weight (kg)
Height (cm)
Waistline/Abdomen (cm)
Emergency Contact Person

First NameLast Name
Phone Number of Emergency Contact Person
Please enter a valid phone number.Format: (000) 000-0000.
Minors: Name of Parent/Guardian

First NameLast Name
Contact Number of Parent/Guardian
Please enter a valid phone number.Format: (000) 000-0000.
Health History
Have you been enrolled to any physical therapy before?

YesNo
Are you currently pregnant?

YesNo
Do you have any allergies?

YesNo
If yes, please list down your allergies below and explain.
Do you have any physical disabilities?

YesNo
If yes, please list down your disabilities below and explain.
Do you have any cardiovascular disease?

YesNo
Do you have any respiratory disease?

YesNo
Do you have asthma?

YesNo
Did you undergo any recent surgery?

YesNo
Do you have any medical condition that you would like to share? Please take note that this information is strictly confidential.
Health Insurance Policy No.
Fitness Tracker
Wellness Goals
Fitness Goals
Desired weight
Consent Agreement
The Pilates/PT studio will provide the space, instructor, exercise program. The client and both parties agreed to fully understand that physical program, exercise can lead to injury. The client is required to have clearance by a doctor, physical therapist or exercise expert(e.g AusRep) for exercise and there are no physical or other health limitations.

I (Name) hereby confirm that I have read and fully understand the above, I agree that Pilates/PT does not replace medical treatment. I am over eighteen years of age and am legally liable for my own decisions/actions. By signing below, it means that I agreed to the terms indicated in this document.
Date Signed

DayMonthYear
Date
Client Signature
Should be Empty:

Pilates/PT Informed Consent Form

Personal Data

Health History

Fitness Tracker

Consent Agreement