Client Form

Your Name (required)

Your Date of Birth (required)

Your Address

Your Email (required)

Your number

Describe the problem you are looking for help with

What day to day activities do you struggle with? Is there any you can't do that you would like to be able to do?

How long have you had this problem for?

Please list any past illnesses or injuries including the date.(it doesn't matter how long ago it was)?

Have you had any MRI scans or investigations related to the problem you are having? If yes , what was the outcome?

Are you currently suffering from or being treated for: (please tick)

Thyroid problemsHeart problemsCholesterolBlood PressureBreathing problemsEpilepsyAsthmaDiabetesRheumatoid arthritisOsteoarthritisOsteoporosisCancerDepressionAllergies (i.e. latex)Oral steroid intakeUnexplained weight lossNight sweatsNo issues
Are you under the care of a consultant? Please give name, department and hospital.
Please list any medication you are taking and the reason for the medication
Is your pain or symptoms worse on a certain day of the week or a certain time of day?
How would you describe your stress levels? Low , medium or high?
LowMediumHigh
How is your sleep? Do you wake during the night? If yes what for and how many times? Do you wake feeling refreshed?
What would you like to achieve from your Pilates sessions?
Please list 3 short term goals:
1.
2.
3.

Please list 3 long term goals:
1.
2.
3.

Are you pregnant or recently had a baby? If yes, have you been given permission by your health care professional to exercise?

Following assessment of the information you have provided, your teacher will decide whether Pilates is a safe and appropriate form of exercise for you. In some cases liaison with a clinician, of whom you are under the care, may be in your best interest, following your given permission. Please advise your teacher prior to beginning any session, if the details you have provided today change in the future. If you have any problems, which may result as a risk during exercise, please contact your doctor, prior to beginning classes. The classes are not a substitute or medical treatment and you must refer to appropriate medical services, should you experience any problems during your sessions. The use of alcohol and recreational drugs is not advisable prior to the time of your session. Please be considerate of your own well-being, as well as the well being of others, while exercising in the studio.
I, the undersigned, have answered all questions truthfully and agree to exercise at my own risk.

Client Signature:

Clear

Print Name:

Date:



Teacher Signature:



Print Name: Keely Thornber
Date: As above