Pilates Class Registration Form

Pilates Class Registration Form
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date of birth

MonthDayYear
Date
Pilates Goals:
Have you practiced Pilates before, if yes for how long and at what level?
What would you like to achieve from Pilates?

Core StrengthBody toningPostureFlexibilityPain reductionPelvic Floor StrengtheningRelaxation
Lifestyle
Occupation
What other forms of exercise do you do? and how often?
Do you have modify your exercise due to a health condition? If so please explain:
Are you under the care of any medical profession at present? (i.e. Dr, Midwife, Physio etc)

YesNo
If yes please explain:
Are you taking any medication? If yes please list and describe what it is for:
Do you have any allergies?

YesNo
If yes please explain:

Type a question

	No	In the Past	Yes
Headaches
Nausea/Dizziness
Breathing problems
Heart problems
High/Low blood pressure
Epilepsy
Stroke
Cancer
Depression
Hypermobility
Artificial joint or implants
Restricted movement in joints e.g. shoulder/back/knee
Back or neck pain
Any other pain
Any other medical condition

If you have answered yes to nay of the above then please explain:
Pregnancy History (females only):

for antenatal classes only.
How many children do you have and how old are they?
Were these natural birth or C-section, please list any complications i.e. forceps delivery:
If you are pregnant now, how many weeks are you and what is your due date?
Please list any pregnancy related health condition, i.e. Anaemia, infection, Pelvic girdle pain, nausea, sciatica, limb swelling, leaking amniotic fluid, uterine bleeding, abdominal cramping, fatigue, headaches, insomnia, placenta problem, pre-eclampsia, diastasis recti, pre term labour in past, diabetes etc
Terms & conditions
If you are unable to attend a class then please inform me as soon as possible (Mobile -07498731041) via text or email (fgphysiotherapy@gmail.com), please leave your name with the message.

When you sign up for a class you agreeing to pay in advance for all 6 sessions. Class fees are non refunable, however if you wish to swap into another class this can be arranged if there is space available.

In the event that I need to cancel a class I will inform you ASAP. When booking onto a pilates course the course dates will be clearly indicated as will any pre-arranged changes to the schedule.
Consent
The Pilates course is designed to progressively build on your skill and ability over the 6 week period.

The Physiotherapist led Pilates classes will begin at a low level and advance depending on your progress.

There exists the possibility of certain dangers when exercising. They inlcude abnormal blood pressure, fainting, irregular, slow or fast heart rhythm, and in rare instances, heart, stroke or death. Every precaution will be taken to ensure your safety. You acknowledge that you are aware of the nature of the classes and that some elements will be physically demanding, and that you are aware of the risks involved. You agree that you are physically capable of participating and accept full responsibility for your own participation in the class. You agree that should any medical or physical reason arise prior to or during the class which is likely to affect your ability to safely participate that you will inform the physiotherapist and agree to withdraw from the class. FG Physiotherapy's liability insurance for personal injury, death or loss or damage to property is limited to any damage so caused as a direct result of the negligence of the company or the physiotherapist. We shall not be liable to you for any indirect or consequential loss or damage including loss of earnings arising from your participation in the classes nor for an aggregate amount greater than the fee paid for the classes.

We can accept no liability for personal injury related to participation if you have been advised against such exercise; you fail to observe instructions on safety or technique; or such negligence is caused by another class participant.

Client Declaration: I have read the above terms of business, cancellation policy and disclaimer, and confirm that I agree to these terms and conditions. I confirm that I have received and read the pre class information sheet.
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Pilates Class Registration Form

Pilates Goals:

Lifestyle

Pregnancy History (females only):

Terms & conditions

Consent