FORM ABOUT YOU

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FORM ABOUT YOU

ALL INFORMATION WILL BE TREATED IN THE STRICTEST OF CONFIDENCE

It's important that I have some details about you, to ensure that you're safe to practice pilates and that I'm aware of any injuries, or issues with your body.

Email *

YOUR DETAILS

Name *

Address: *

Telephone numbers: *

Email Address: *

Gender *

Male

Female

Other

Prefer not to say

Date of Birth: *

YYYY

Occupation:

Sports, Hobbies *

Emergency Contact Details (please provide name, contact numbers & email address if you have it) *

YOUR BACKGROUND & YOUR HEALTH

DOES YOUR WORK/SPORT INVOLVE ANY OF THE FOLLOWING?¨ *

Driving

Standing

Lifting heavy weights

Bending

Any other repetitive action

IS THIS THE FIRST TIME THAT YOU HAVE PRACTISED PILATES?

Yes

Clear selection

If you answered NO to the above question, have you previously attended: *

Body Control Pilates Matwork classes

Other Pilates matwork classes

At home (Youtube, DVD, book)

How many pilates classes did you attend previously?

0-5

5-10

10-20

20+

Clear selection

MEDICAL QUESTIONS *

Yes

N/A

Has your Doctor ever said that you have any sort of heart trouble or defect?

Do you feel pain in your chest when you undertake physical activity?

Do you lose your balance because of dizziness?

Do you ever lose consciousness, feel faint or dizzy?

Do you have high blood pressure?

Have you had major surgery in the last 10 years?

Have you had minor surgery in the last 2 years?

Do you suffer from asthma, diabetes or epilepsy?

Have you ever been told you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that maybe made worse by exercising?

Do you suffer from back or neck pain?

Do you have pain or restricted movement in any other joints e.g. hip, knee, ankle, shoulder etc?

Have you ever been diagnosed as hypermobile (excessive joint mobility)?

If you have answered "Yes" for ques 8-12, do you have medical permission to exercise?

Are there any movements that cause you pain?

Are you taking any drugs or medication which may affect your ability to exercise?

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

Yes

N/A

Has your Doctor ever said that you have any sort of heart trouble or defect?

Do you feel pain in your chest when you undertake physical activity?

Do you lose your balance because of dizziness?

Do you ever lose consciousness, feel faint or dizzy?

Do you have high blood pressure?

Have you had major surgery in the last 10 years?

Have you had minor surgery in the last 2 years?

Do you suffer from asthma, diabetes or epilepsy?

Have you ever been told you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that maybe made worse by exercising?

Do you suffer from back or neck pain?

Do you have pain or restricted movement in any other joints e.g. hip, knee, ankle, shoulder etc?

Have you ever been diagnosed as hypermobile (excessive joint mobility)?

If you have answered "Yes" for ques 8-12, do you have medical permission to exercise?

Are there any movements that cause you pain?

Are you taking any drugs or medication which may affect your ability to exercise?

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

If you answered Yes to question 16 above, by your...

Yes

Osteopath

Physiotherapist

Chiropractor

Other

Clear selection

Do you give me permission to contact them?

Yes (If yes, please provide their contact details below)

N/a

Option 3

Clear selection

Contact Details of Practitioner (name and contact number):

Are you or could you be pregnant now? *

Yes

N/a

If 'yes' to the above question, when are you due?

Have you been pregnant in the last 6 months?

Yes

Clear selection

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

Vaginal

Caesarean

Vaginal with intervention (eg. Forceps)

Clear selection

FURTHER MEDICAL QUESTIONS

Do you often get headaches? *

Yes

Is your blood pressure? *

High

Normal

Low

Don't know

YOUR AIMS

What are your reasons for taking up pilates?

What health or physical goals would you like to achieve over the next 3 months? (try to be as specific as possible e.g. Instead of 'to get more flexible' write 'I'd like to to be able to be able to tie my own shoes laces')

Please list any health problems you suffer, not already mentioned, that may affect your ability to exercise. If you have answered YES to any of MEDICAL QUESTIONS above, we advise you consult with your medical practitioner before you start Pilates Classes. Please give further relevant details below, in confidence, to any questions you ticked YES. Are there any factors that I should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?

Are there any factors that I should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?

Option 1

Clear selection

IMPORTANT INFORMATION - FINAL PART!

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 which 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 Body Control Pilates exercises involve hands-on correction 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, in any circumstances, be shared with a third party without my written consent, unless that party is another (Body Control) Pilates teacher who will teach me.
• 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.

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.

Yes

Clear selection

Please provide your first name & surname below. I will bring this form to your first class and then we can both sign in person.

A copy of your responses will be emailed to the address you provided.

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