Pilates Informed Consent Form
Hilal Leigh Pilates Health Questionnaire for Pilates Practice
Register Date
*
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Month
-
Day
Year
Date
Personal Data
Full Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Occupation
Height (cm)
Weight (lbs)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person
First Name
Last Name
Phone Number of Emergency Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Hobbies/Sports
Have you ever practiced 'Pilates' before?
Yes
No
What is your daily activity?
Were you recommended by a GP/Physiotherapist/Osteopath to do Pilates?
Yes
No
If yes, indicate Physician name, Specialty & Address below
What are your reasons for taking up Pilates?
Health History
Do you smoke?
Yes
No
Do you drink alcohol more than three times/week?
Yes
No
Is your stress level high?
Yes
No
Do you take any medication on a regular basis? (if yes please list medication and reasons for taking)
Yes
No
List of medications & reasons for taking
Are you pregnant?
Yes
No
If your answer to above question is "Yes", please indicate how far on?
Is this your first pregnancy?
Yes
No
If your answer to above question is "No", how many pregnancies have you had?
Have you undergone a C-Section in the past 6 months?
Yes
No
Do you have any of the following conditions? (High/Low Blood Pressure, Heart Conditions, Shortness of Breath, Major Surgery in the last 12 months, Severe Osteoporosis, Arthritis, Spondylitis, Spondylosis, Back Pain (upper,middle,low), Neck Pain, High Cholesterol, Diabetes, Asthma, Epilepsy, Current Joint/Muscle Pain or Injury.
Yes
No
If your answer is "Yes" to above question, please explain your condition(s) below. ***YOU SHOULD BRING A NOTE FROM YOUR DOCTOR STATING THAT YOU CAN BEGIN PILATES PRACTICE IF ANY OF THE ABOVE CONDITIONS EXIST***
Have you ever had any surgery and/or major injuries? (If your answer is "Yes", please explain below.)
Yes
No
History of Surgery And/Or major injuries.
How did you hear about Hilal Leigh Pilates?
Friends/Family
Social Media
Internet
Other
Email
example@example.com
Terms & Conditions
You must inform your Instructor before commencing a class or private session, if for any reason, your health or ability to exercise changes from the information you have provided on this form.
Classes or private sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercise, you should refer back to your medical practitioner.
HILAL LEIGH PILATES PERSONAL SPORT COACHING SERVICES accepts no responsibility for clients' death or injuries sustained during sessions.
Clients agree that no claims will be made against HILAL LEIGH PILATES PERSONAL SPORT COACHING SERVICES or staff for any reason whatsoever.
HILAL LEIGH PILATES PERSONAL SPORT COACHING SERVICES shall not be responsible for any claims, demands, injuries, damages or actions for negligence arising on account of death or due to injury, out of or in connection with the use by a client of any of the services of HILAL LEIGH PILATES PERSONAL SPORT COACHING SERVICES.
The client hereby holds HILAL LEIGH PILATES PERSONAL SPORT
COACHING SERVICES, its associated employees harmless from all claims which may be brought against them by or on a client's behalf for any such injuries or claims aforesaid.
By signing below, it means that I agreed to the terms indicated in this document.
Client Signature
Submit
Submit
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