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PLEASE TICK THE BOX(ES) THAT APPLIES TO YOU

Are you pregnant?

YesNo

Prenatal

n/a1st Trimester2nd Trimester3rd Trimester

Postnatal - how recent was the birth?

n/a1-4 weeks5-8 weeks2-3 months4-6 months7-9 months10-12months

 
PLEASE TICK THE BOX(ES) IF YOU SUFFER WITH ANY OF THE FOLLOWING:

AsthmaAllergiesDiabetesHypermobileOsteoarthritisArthritisOsteoporosisEpilepsyOsteopeniaEye complaintBack problemsHigh/low blood pressureAnxietyDizziness/feeling faintMigraineDifficulty in hearingDifficulty in seeing

Notes provided?
YesNo

If notes are not provided we may seek permission to liaise with your health professional to gather more information about your condition?
YesNo

Please Note
Do not exercise if you are feeling unwell or have a cold/fever. Please advise the teacher before class if for any reason your ability to exercise has changed. This includes if you then answer YES to any questions already asked.
You may need to check with your doctor if you should change your exercise plan.
The very nature of Pilates requires “hands on” guidance from your teacher. If you would prefer to avoid this method please let me know.
It is your responsibility to observe instruction on safety and technique on performance or use of the equipment and it is advisable not to eat a heavy meal less than two hours before exercising.

 

YOUR CONSENT

 
 

Please accept my filling in this form, consent, date and submission as an e-signature in agreement with your terms and conditions.

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