Pregnancy Pilates Participant Form
Please complete this form ahead of attending your first pregnancy Pilates class at goPhysio.
Email address *
First Name *
Your answer
Surname *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Telephone *
Your answer
GP Name & Address
Your answer
Pilates Aims
Why have you decided to commence Pilates?
Your answer
What aspects of your health would you like to concentrate on?
What are the three main aims that you are hoping to achieve with your Pilates program?
Aim One
Your answer
Aim Two
Your answer
Aim Three
Your answer
Lifestyle
Are you currently working? If so, what is your occupation?
Your answer
Does your occupation involve any repetitive movements or prolonged postures? If yes, please explain briefly.
Your answer
Are you involved with any other sports and/or hobbies? If yes, please briefly outline.
Your answer
Medical Questionnaire
Are you currently experiencing OR ever been diagnosed with any of the following conditions? *
Yes
No
Back pain
Pain at the front or back of your pelvis
Any other muscle or joint conditions
Heart problems
High or low blood pressure
Circulatory problems e.g. blood clots
Diabetes
Abnormal vaginal bleeding
Pre-eclampsia
Incompetent cervix
History of spontaneous miscarriage
Anaemia
Epilepsy (Grand mal seizures)
Abnormal placental function or position
If you have answered yes to any of the above, please provide further details.
Your answer
Is this your first pregnancy? *
If no, how many other children do you have and what are their ages?
Your answer
What is your due date? *
MM
/
DD
/
YYYY
Have you had any complications with your pregnancy? *
If yes, please give details
Your answer
Have you ever had an episode of low back pain?
If yes, approx. how many previous episodes of low back pain have you had?
Your answer
Have you had any recent injuries or surgery? Please give details.
Your answer
Pilates Participation Informed Consent
The Pilates program will begin at a low level and will be advanced in stages depending on your fitness level. Pilates sessions may be stopped because of signs of fatigue or strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or other discomfort. There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body's exact response to exercise. Efforts will be made to minimise these risks by evaluation of preliminary information relating to your health and by observations during exercising. Emergency equipment and trained personnel are available to deal with unusual situations that may arise.

I understand that the Pilates program will be specifically designed as a personal training plan, and will take into account details given in my health questionnaire. Therefore, this program of exercise should only be undertaken when in a Pilates class, or when I have been given specific instructions to exercise on my own.

Signed *
Your answer
Date *
MM
/
DD
/
YYYY
Thank you
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