Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone Number * Emergency Contact name and details Have you done Pilates before? * Yes No Other Medical Screening Do you have any medical issues, health concerns that may limit you in a Pilates exercise class? If yes please give details. Do you have or have had any of the following? Osteoporosis Heart Problems Low or High blood pressure Diabetes Epilepsy Dizziness/feinting Arthritis ( osteo or rheumatoid) Nerve pain or sciatica Low back pain Cancer Balance issues Asthma or other breathing issues Stroke Musculoskeletal pain eg neck, shoulder pains etc. History of surgery? please list any musculoskeletal surgeries eg, lumbar discectomy, total knee replacement etc? Are you pregnant? If yes how many weeks? Please make sure your GP is happy for you to take part in a Pilates class. If you are postnatal please wait for your midwife/GP 6 week check before starting Pilates classes. Disclaimer and Consent to attending Online Pilates Class * To be completed by all. I declare that I have read the registration form thoroughly and understand its content. I have answered the questions to the best of my ability and will update my Pilates instructor of any changes to my health or if I become pregnant. I understand that my failure to give any updates on my health could result in a risk to my wellbeing attending a class. All exercises will be clearly explained and be progressed from beginner to advanced levels. It is important that I exercise to my own level of ability and comfort. Whilst every care will be taken, there does exist the possibility of certain dangers when exercising and it is impossible to predict the exact response to exercise. These can include abnormal blood pressure, feinting, irregular heart rhythm and in rare instances a heart attack, stroke or death. Every effort will be made to minimize this risk by evaluation of the health information given in this questionnaire but it is important to also listen to the cues that are given by the instructor to modify an exercise safely. I understand that it is my responsibility to follow the teacher’s instructions and modifications as best I can to reduce risk of injury. I also have responsibility to stop an exercise if it feels too hard, or is causing pain or discomfort or excessive strain on my body. No liability can be accepted if you are doing this type of exercise against the medical advice of a doctor or another health professional. Online classes have limited verbal feedback due to the nature of the online setting and therefore you are responsible to exercise safely and no liability can be accepted if you injure yourself whilst exercising in this format. I will let an instructor know if I have experienced any problems during the class or have felt unwell or pain with any of the exercises. A recording of the class may be taken to send to participants that are unable to join at the time, this will be of the instructor not the participants. Thank you. Please sign and date (by typing name I am signing this disclaimer and consent to attend a Pilates online class) Thank you!
