Tipperary Physio Pilates Form

Name*

First NameLast Name

Date of Birth*

Age*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Gender*

MaleFemaleOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

Emergency Contact Phone Number*

Please enter a valid phone number.

How did you hear about us?*

Have you ever attended Pilates before?*

YesNo

Are you currently Pregnant?*

YesNo

Have you recently gave birth*

YesNo

Have you any cardiovascular (blood flow/pressure) disease?*

YesNo

Have you any respiratory (breathing/ air flow) disease?*

YesNo

Do you have asthma?*

YesNo

Do you suffer with Low Back Pain?*

YesNo

Have you recently undergone surgery?*

YesNo

Do you ever lose balance due to dizziness or do you ever lose consciousness?*

YesNo

Do you have a bone or joint problem that could be made worse by change in physical activity?*

YesNo

If you have answered yes to any of the above please provide more information in the box below.*

Do you have cancer?*

YesNo

If yes please provide further information regarding diagnosis and treatment below.*

Are you awaiting any outstanding investigations or treatments?*

YesNo

Please provide information if yes*

Do you have any other diagnosed medical or health conditions? (please include any abnormal BP)*

YesNo

Please provide information if yes*

Do you smoke?*

YesNo

Do you take drugs?*

YesNo

Please list any medications that you have been prescribed by your doctor or drugs that you are currently taking.*

Is there any reason why you should not participate in physical activity or have you ever been told not to participate in any exercise by your GP?*

YesNo

please note all medical information is strictly confidential.

If you have answered yes to any of the above questions then you may need written
permission from your GP before participating in any physical and aerobic fitness activity.

Please tell us what you would like to gain from attending our Pilates classes?

I hereby confirm that all the above information is correct and accurate at the time of activity. I know of no reason why I should not participate in a Pilates program.

I understand the Pilates program will begin at a low level and will be advanced in stages depending on my fitness level.

I understand that I will only complete the level that feels right for me and I understand that I can stop at any time during the class if feel fatigue or any discomfort.

I will notify my instructor should this happen. I understand that as this is a face to face group/or 1:1 class and my instructor may help correct and provide feedback on my technique using light touch or verbal cues.

I understand that if I wish not to be touched I will speak to my instructor
prior to class.

Kilkeel Physiotherapy Clinic assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, I will consult my doctor prior to physical activity.

Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. I understand the risk of exercise can include abdominal body pressure, fainting, irregular, fast or slow heart rhythm, and in rare circumstances heart attack, stroke or death.

To minimise these risks I have completed this form and declared all preliminary information prior to starting this class related to my health and fitness. If anything should change to my health during the class I will immediately inform my instructor. I understand my information is confidential.

I hereby affirm that I have read and fully understand the above, 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.

Read "Terms & Conditions" Read "Private Policy"

I Agree to Terms and Conditions*

Yes

I Agree to Privacy Policy*

Yes

I Agree to Release & Waiver*

Yes

Date Signed:

Date

Client Signature

Pilates Form

Personal Information

Health Questionnaire

Your Goals

Consent Agreement: