Client Health Questionnaire

Client Health Questionnaire

Please Read and complete the following questions as fully as you can. The information you share will allow me to tailor your class experience to your specific needs. All details given on this form will be kept in the strictest confidence. Please keep me updated and advise me immediately if any of the given information changes. Thank you.
Full Name *
Date of Birth *

Day Month Year
Phone Number

Area Code Phone Number
E-mail Address *
Occupation
Previous Pilates Experience *
How long and where?
Other movement or exercise history? *
General Health Information
Please tick all applicable *

High/low blood pressue Joint problems Arthritis Back problems Neck/shoulder problems Respiratory problems Diabetes Epiepsy Neurological conidtions Dizziness/Fainting Stroke Heart disorder Any other injuries/conditions Not applicable
If you ticked any of the above health conditions, please give further details
How is your general health and fitness? *
Are you referred by a health practitioner or therapist? If yes, by whom?
Have you had any operation or injuries in the last year? If so, please explain if relevant.
Do you smoke?
For Woman only: Are you pregnant, or have you had a baby in the last 18 months?
What are your aims and expectations in attending Pilates classes? *
Please advise the teacher before commencing a class if for any reason your ability to exercise has changed. Exercise should be performed at a pace which is comfortable for you. PAIN is the body’s warning system and should not be ignored. Please inform the teacher if you feel any discomfort during or after a session.

Pilates exercises are safe but, as with all forms of physical exercise, if you are unsure it is prudent to consult your doctor before starting classes. The classes 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 class if:

(a)             Your doctor has, on health grounds, advised you against such exercise.

(b)            You fail to observe instructions on safety or technique.

(c)             Such injury is caused by the negligence of another participant in the class.
I have completed this questionnaire to the best of my knowledge and I have not withheld information that may be significant or relevant. I undertake to advise of any significant changes to my health and present condition, including health and surgery. I understand that all exercise carries a risk of injury. I accept responsibility for my own body and stop exercising if I need to. I consent to exercising on my own risk. I understand that Pilates exercises involve hands on correction and I hereby give consent for my teacher to work in this way.
I have read and understood the above statement *

Yes
I consent to my details being stored by RePilates and agree to the Data Protection Policy which can be found at the following link-http://www.re-pilates.co.uk/privacy-policy.html *

Yes No
Client Signature

Clear
By submiting the form, you have given consent for us to contact you via email regarding to the relevant class you are booked into. More information regarding the company's privacy policy can be found on www.re-pilates.co.uk/privacy-policy
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Client Health Questionnaire

General Health Information