Client Enrolment Form

You are here:

Personal Details

Sex

Emergency Contact Details

Medical History

Does your work/sport involve any of the following (please tick)
Will this be the first time you have practiced Pilates, Yoga, barre or the Feldenkrais® Method?
If NO, have you previously attended:
Number of classes attended:
Are you, or could you be, pregnant now?
Have you had a baby in the last six months?
If YES, was this a:
Has your doctor ever said that you have any sort of heart trouble or defect?
Is there any history of heart disease in your immediate family (under the age of 55)?
Do you feel pain in your chest when you undertake physical activity
Have you ever had chest pain when you are NOT doing physical activity?
Do you often get headaches or migraines?
Do you lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy?
Is your blood pressure:
If HIGH, is it being medically controlled?
Have you ever been told that you have high cholesterol?
Have you ever had asthma, chronic bronchitis or any other chest ailments?
Do you suffer from diabetes or epilepsy?
Have you ever been told that you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that may be made worse by exercising?
Do you suffer from back or neck pain?
Do you have restricted movement in any other joints (e.g. hip, knee, ankle, shoulder)?
Have you ever been diagnosed as hypermobile (excessive joint mobility)?
Are there any movements that cause you pain?
Are you taking any drugs or medication which may affect your ability to exercise?
Are you recuperating from any recent illness or injury?
Have you had minor surgery in the last two years?
Have you had major surgery in the last 10 years?
Have you been recommended to take up Pilates by a specialist practitioner?
If YES, by your:
Do you hereby give us permission to contact them?
If YES, please state their name and contact number:
Have you ever been diagnosed with a chronic or neurological illness?

Your Aims