Medical Form

Medical Form

The Pilates and Strength Coach - Natasha Haresign Pilates
ALL INFORMATION WILL BE TREATED IN THE STRICTEST CONFIDENCE
Full Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Phone Number*
E-mail Address*
example@example.com
Emergency Contact Number*
Occupation*
HEALTH HISTORY
Height*
meters
Weight*
kg
Gender*
Sports / Hobbies*
How did you hear about The Pilates and Strength Coach? Who referred you?*
What does your typical day involve? eg: sitting at a computer, lifting, standing for long periods etc*
Will this be the first time you have practiced Pilates or Stength and Mobility? If "NO" what is you experience, when and where.*

Please give information about your health. Do you have any of the following?*

Rows	Yes	No
Heart trouble or defect
Pregnant
Muscle cramps
Shortness of breath / Asthma
DIabetes
High / Low Blood pressure
Joint problems
Vertigo
Fractures
Chronic illness
Chronic Fatigue
Menopause
Seizures
Dizziness
Osteoporosis

Do you suffer from back pain? Please describe.*
Have you had any past surgeries? Please describe.*
Have you been diagnosed at any time with cancer? Please describe.*
Are there any movement that give you pain? Please describe.*
Are you currently taking any drugs or medication? Please describe.*
Have you been referred to Pilates by a specialist practitioner? Please give details.*
Do you have any other health concerns you would like to share? Please give details.*
What are your goals? What do you want most from your Pilates or Strength and Mobility experience?*
Acknowlegement of Risk and Waiver of Liability
I understand that I will be participating in a fitness programme that will reqiuire physical exertion.

Before beginning the programme, I was ask by my instructor if I had any physical limitations, or whether I am taking medications or receiving any medical treatment that might make it unsuitable or unsafe for me to particiapte in this fitness programme. There is no such limitations, medication, or medical treatment other than those disclosed in this form.

I understand that by signing this statement, I am agreeing to not hold The Pilates and Strength Coach - Natasha Haresign, it's employees, owners, agents, or insurers resposible for any bodily injury or property damage that may suffer as a result in my participation in this fitness programme, in any venue, at home or elsewhere.

As such, I understand and agree that The Pilates and Strength Coach - Natasha Haresign it's employees, owners, agents or insurers will not be held liable for any bodily injury or or property damage that may result either directly or indirectly in my participation in said fitness programme, in any venue, at home or elsewhere.

Cancellation Policy: 24 hours notice is required to change or cancel any 1-2-1 appointments.

Failure to give 24 hours notice will result in the client being charged the full appointment fee.

Very occassionally we will take photos/videos for marketing and social media purposes.

Block bookings will not be subject to a refund.
Please tick to confirm that you have read, understand and fully agree to the above terms and that all the deatils given are correct.
Signature
All information will be treated in the strictest confidence.

GDPR: The Pilates and Strength Coach - Natasha Haresign is committed to protecting your personal data on this form. It is retained for the sole and specific purpose of reminding instructors of your health issues you may have that would affect your fitness programme or exercise experience. You have the right to remove your data at any time should you leave the fitness programme. Your personal information will be stored securly and privately.

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Medical Form

HEALTH HISTORY

Acknowlegement of Risk and Waiver of Liability