Pilates Yoga Massage Health Questionaire

Mind Body Spirit PilatesYogaWeights
www.GillianGreenwood.com
pilates@gilliangreenwood.com

Full Name*

First NameLast Name

E-mail

Address*

Mobile Phone Number*

Landline Phone Number

Date of Birth*

How did you hear about us?*

details below please

Occupation Past/Present*

Sports*

Hobbies*

Are you a beginner?/what experience do you have of Pilates?*

N.B. Regarding all the questions below. If you have extensive medical notes you may telephone/write to Gillian with the details and put the very minimum on here: Do you have a heart problem or defect?*

Do you have osteoporosis, arthritic joint or any bone or joint problem that may be made worse by exercise?*

What operations/injuries have you had?*

Ladies - are you pregnant? If so how many months?*

Ladies - have you had children? Please state type of delivery and age of children*

Do you suffer from Neck-ache?*

Do you suffer from Upper back-ache?*

Do you suffer from Mid back-ache?*

Do you suffer from Lower back-ache?*

If so, do you know why?

Is your blood pressure low/normal/high?*

Are there any movements that cause you pain? e.g. raising your arm, bending to side.*

Main reason for attending my class?

I understand the basics of Pilates from prior experience, have watched Gillian's video on her website or have read her book:

Pilates & Lifestyle with an introduction by Julian Clary

https://www.amazon.co.uk/dp/B072KFY4Y9/ref=rdr_kindle_ext_tmb

Please advise Gillian before commencing any session if, for any reason, your health or your ability to exercise changes. Gillian is very knowlegable with Ante/post-natal exercise so she will probably accept you in class, but you need to speak to her and request a different form. It is inadvisable to do Pilates Yoga between weeks 8 to 14 of pregnancy, unless by special arrangement with Gillian. It is also wise to wait six weeks after the birth before resuming Pilates (if you wish to start before please speak to Gillian). Pilates Yoga exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates Yoga 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. Gillian 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 and such injury is caused by the negligence of another participant. In class 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 Gillian immediately if you feel any discomfort during a session. Please also inform Gillian if you felt any discomfort after a previous session. Pilates Yoga exercises may involve hands-on correction and I hereby consent for Gillian 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 Gillian may use the contents of this form, and any other information I may later provide, for teaching you, 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 Pilates Yoga teacher who will teach me, may be retained by Gillian for a period of time such as complies with professional, legal and insurance requirements that they must fulfil. I confirm agreement for Gillian 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.

(No refunds. Private lessons require you to give 24hrs cancellation notice or full fee is payable.)

By signing your name below it shows you have read and agree to the terms and conditions above

Name*

First NameLast Name

Date*

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