Alive Pilates Studio Pre-Exercise Screening

Alive Pilates Studio

Pre-Exercise Screening Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

DayMonthYear
Month/Date/Year
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Have you ever been told you have a heart condition?*

YesNo
Are you pregnant/returning from exercise after pregnancy?*

YesNo
If yes, have you received clearance from a medical professional?*

YesNo
Are you experiencing any of the following?

HypertensionType 1 diabetesSeizure disorderThyroid disease
If yes to any of the above, please upload medical clearance from your healthcare professional.*

Cancelof
Have you ever had a stroke?*

YesNo
Do you ever have unexplained pains in your chest at rest or during physical exercise?*

YesNo
Do you consistently feel faint or suffer from spells of dizziness?*

YesNo
Do you suffer from asthma and require medication?*

YesNo
Do you suffer from type I or II diabetes?*

YesNo
Do you suffer from high blood pressure over 140/90 or low blood pressure below 100/80?*

YesNo
Do you suffer from any major muscle or joint conditions that may limit you or be aggravated by physical activity?*

YesNo
Please describe below:*
*We highly recommend participating in our 'Studio Pilates' classes before partaking in one of our group classes.
Do you suffer from any medical conditions that may be made worse by participating in physical activity?*

YesNo
Please describe below:*
*We highly recommend participating in our 'Studio Pilates' classes before partaking in one of our group classes.
Disclaimer
You should consult your physician or other healthcare provider before changing your diet or starting an exercise program.

I understand that there is a risk of injury associated with participating in classes at Alive Pilates Studio.

I hereby assume full responsibility for any and all injuries, losses and damages that I incur while attending, exercising or participating in classes at Alive Pilates Studio.

I hereby waive all claims against Alive Pilates Studio, it's instructors, or partners of individually or otherwise, for any and all injurues, claims or damages that I might incur.

I understand and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to my heart, safety, comfort, or physical condition if I engage or participate.
I agree with the terms and conditions.*

Clear
How did you hear about us?*
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