Standard Client Enrolment Form

Name *

First Name Last Name

Email *

example@example.com

What type of sessions are you planning on attending? *

Group - Standard Group - Healthy Back Course (for back pain) Private Group & Private

Address *

Street Address
Street Address Line 2
City	County
Postcode	Country

Mobile Number *

Gender *

Date of birth *

Date

Occupation *

Sports / Hobbies

Name *

First Name Last Name

Mobile Number *

Email *

example@example.com

1. Have you practiced Pilates before?? *

Yes No

1b. How many classes have you attended?

1-5 6-10 11-20 21+

2. Has your doctor ever said that you have any sort of heart trouble or defect? *

Yes No

2a. Do you have medical clearance to exercise? *

Yes No

3. Do you feel any pain in your chest when you undertake physical activity? *

Yes No

3a. Do you have medical clearance to exercise? *

Yes No

4. Are you, or could you be, pregnant now? *

Yes No

Please be aware, group classes are not suitable during pregnancy. Classes are suitable for post natal clients from 6 weeks post natal (normal delivery) and 12 weeks post natal (caesearean) with a pregnancy qualified teacher. Please do not complete this form - email sam@mylocalpilates.com to discuss your options.

5. Have you been pregnant in the last six months? *

Yes No

Please be aware, group classes are not suitable during pregnancy. Classes are suitable for post natal clients from 6 weeks post natal (normal delivery) and 12 weeks post natal (caesearean) with a pregnancy qualified teacher. Please do not complete this form - email sam@mylocalpilates.com to discuss your options.

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

Vaginal delivery Caesarean Vaginal delivery with medical intervention (e.g. forceps)

7. Do you often get headaches? *

Yes No

7a. Please give details *

8. Do you ever... *

Lose consciousness, feel faint or dizzy? Lose your balance? None of the above

8a. Please give details *

9. Is your blood pressure... *

High Low Normal Don't Know

9(H). Is your blood pressure stabilised with medication, and do you have medical clearance to exercise? *

10. Have you had major surgery in the last 10 years? *

Yes No

10a. Please give details *

11. Have you had minor surgery in the last 2 years? *

Yes No

11a. Please give details *

12. Do you suffer from... *

Diabetes Epilepsy Asthma None of the above

12(D). Is your diabetes diet or medication controled? *

12(A). Do you require medication during exercise? *

12(E). Have your seizures been stabilised by medication? *

13. Have you been diagnosed with... *

Osteoporosis Osteopenia None of the above

13b. Do you know your T-Score?

14. Have you ever been told that you have a joint or soft tissue problem that may be made worse by exercising? *

Yes No

14a. Please give details *

15. Do you suffer with... *

Back pain Neck pain None of the above

15a. Have you had a formal diagnosis in relation to your pain? If so, please give details including approximate dates of episodes. *

16. Do you have pain or restricted movement in any of these joints... *

Hip Knee Ankle Shoulder Elbow Wrist None of the above

16a. Please give details *

17. Have you been diagnosed as hypermobile? (excessive joint mobility) *

Yes No

17a. Please give details *

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

Yes No

18a. Please give details *

19. Do you suffer from digestive complaints (ulcers, reflux, colitis etc.)? *

Yes No

19a. Please give details *

20. Have you noticed any bowel or bladder dysfunction? *

Yes No

20a. Please give details *

21. Have you noticed any recent unexplained weight loss? *

Yes No

21a. Please give details *

22. Have you been diagnosed with any form of cancer? *

Yes No

22a. Please give details *

23. Do you suffer from any neurological conditions or diseases? *

Yes No

23a. Please give details *

24. Do you suffer from any inflammatory conditions or diseases, (such as rheumatoid arthritis, polymyalgia rheumatica etc.)? *

Yes No

24a. Please give details *

25. Have you suffered any broken or fractured bones (including stress fractures)? *

Yes No

25a. Please give details *

What are your reasons for taking up Pilates?

Is there any other information not asked for above, that you feel may be relevant to you attending classes?

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

GP Physiotherapist Osteopath Chripractor Massage Therapist Other Fitness Instructor

Do you hereby give us permission to contact them? *

Yes No

Practitioners Name

Practitioners Phone Number

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 an 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 Local Pilates 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 Local Pilates to email me directly with information on classes e.g. to advise changes to class times and teachers scheduled. My Local Pilates may contact me via email me until my account becomes inactive. i.e. I choose not to book a subsequent term or Class Pack. Subscription to the monthly Newsletter (sent via MailChimp) is an Opt-in preference. I understand that I have the right to unsubscribe from the newsletter at any time.

Sign Here *

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Date *

Date

Part 1 - Personal Details

Emergency Contact Details

Part 2 - Your background and your health

Part 3 - Important Information & Permissions