New Customer Registration Form

Unique Movement

Fairlands, Randburg

, 2030

charni@uniquemovementl.com

www.uniquemovement.com

063 074 4112

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail*

example@example.com

How did you hear about us?*

Please Specify*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Gender*

MaleFemaleOther

Occupation:*

Sports & Hobbies :*

Does your work, hobby or sport involve any of the below:*

Please specify if you selected other

Have you done Pilates before:*

YesNo

If yes, how many lessons and where?

Have you ever been diagnosed with any heart trouble or defect*

YesNo

If yes, please specify

Do you feel any pain in your chest when you exercise?*

YesNo

Do you ever lose your balance because of dizziness, loose consciousness or feel vertigo?*

YesNo

Is your blood pressure*

HighLowNormal

If high, is it regulated by medication? If yes, please specify.

Are you taking any other substances or medication which may affect your ability to exercise?*

YesNo

If yes, please specify.

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

YesNo

If yes, please specify.

Do you suffer from any of the below:*

AsthmaDiabetesEpilepsyNone

Do you / have you had a terminal illness?*

YesNo

If yes, please specify.

Have you every been told you have arthritic joints, osteoporosis, osteopenia, or any bone or joint problems that may be made worse by exercising?*

YesNo

If yes, please specify.

Do you often get headaches?*

YesNo

Do you suffer from back and/or neck pain*

YesNo

If yes, please specify.

Do you have any pain or restricted movement in any other joints (eg, hip, knee, ankle, shoulders?*

YesNo

If yes, please specify.

Are there any movements that cause you pain?*

YesNo

If yes, please specify.

Have you every been diagnosed with hypermobility?*

YesNo

Have you ever been recommended to take up Pilates by a specialist practitioner?*

If you selected other, please specify.

Do you hereby give us permission to contact your specialist practitioner? if yes, please provide details blow

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you or could you be pregnant?*

1st trimester2nd trimester3 trimesterNo

Have you been pregnant in the last 6 months?*

YesNo

If you have had a baby, how was it delivered?*

VaginalCesareanVaginal with intervention (eg. Forceps)None

Please list any health problems you suffer from, not already mentioned, that may affect your ability to exercise.

What are your reasons for taking up Pilates?*

What health or physical goals would you like to achieve over the next 3 months*

What long-term health or physical goals would you like to achieve over the next 12 months*

Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes.

It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise.

Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions. These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner.

The teacher can accept no liability for personal injury related to participation in a session if:

• Your doctor has, on health grounds, advised you against such exercise

• You fail to observe instructions on safety or technique

• Such injury is caused by the negligence of another participant in the class/studio

Exercise should be performed at a pace that feels comfortable for you. Pain is the body’s warning system and should not be ignored. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session.

I understand that Pilates exercises involve hands-on corrections and I hereby consent for my teachers to work in this way.

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

I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information:

•will be used in confidence and stored securely

•will not, under any circumstances, be shared with a third party without

my written consent.

• may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfil

I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time.

Signature*

Date*

Date

Customer Details:

Emergency Contact details:

Client background and health:

Your goals

Important information: