PLEASE TICK THE BOX(ES) THAT APPLIES TO YOU My doctor has said I have a heart condition and that I should only do exercise recommended by himI feel pain in my chest when I do physical activity or when I am at restI have joint problems or an artificial jointI have broken a boneI have had operations or injuries in the last six monthsI have had operations in the pastI have had (a) major illness(es)I have had a strokeI have musculoskeletal problems (eg: slipped disc, whiplash etc.)I am currently taking medication which you should be aware ofI have recently had a kidney/bladder infectionI suffer from skin allergies / contagious skin rashes 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 I have answered the above questions to the best of my knowledge I understand that all exercise carries a risk of injury I accept responsibility for my own body and will stop exercising if I need to I will stop if I experience pain Please accept my filling in this form, consent, date and submission as an e-signature in agreement with your terms and conditions.
