HEALTH DECLARATION FORM

Pilates Class Health Assessment Form

First name

Last name

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

GP Name:

GP Address:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone Number:

Privacy Statement

By signing below, you explicitly consent to us processing the personal data you have included in this form in accordance with our Privacy Policy that is set out overleaf.

We may from time to time send you our Newsletter including details of our goods or services that we feel may interest you, by email or post. This may include special offers, competitions, blog posts, videos and relevant articles relating to Health and wellbeing and surveys to improve our service. You may opt out of receiving such communications at any time. If you would NOT like to receive such offers, please tick below:

By Post

By Email

Pilates Aims

Why have you decided to commence in Pilates?

Has your GP or Health Professional recommended that you start Pilates?

Yes

No

If yes, please state who

Have you practised Pilates before?

Yes

No

What aspects of your health would you like to concentrate on?

What are the three aims that you are hoping to achieve with Pilates?

Lifestyle

Are you currently working? If so, what is/was your Occupation

Does your occupation involve any repetitive movements or prolong postures? If so, please specify

Are you carrying out any other sports and/or hobbies

Do you frequently carry out some form of exercise, if yes state

Medical Questionnaire

1) Has there been any change in your medical history since last attending classes? If yes, please give further details in section 12 below

Yes

No

2) Have you ever had an episode of low back pain?

Yes

No

3) If yes a:How many previous episodes of low back pain have you had?

b. Have you experienced the following recently:

4) Have you recently had any injuries or surgery? If yes, please specify with approx.

Yes / No Date/Year

5) Do you currently have any of the following conditions? If yes, please include further details on question 13

6) Please tick any of the following conditions that you have been diagnosed with or had treatment for

7) Have you been advised to avoid physical activity?

Yes

No

8) Do you feel pain in your chest at rest or when exercising?

Yes

No

9) Do you ever lose consciousness or control of your balance due to dizziness?

Yes

No

10) Are you pregnant or have you given birth in the last 3 months?

Yes

No

If yes, how many weeks? Expected date of delivery?

Have you had any complications during this or a previous pregnancy any pain/ joint restrictions? Yes / No If yes, please give details

11) Please give details of any current medication that you are taking

12) Are you under the doctors supervision for any medical condition not already mentioned? Yes/ No

Please include any Back, Neck or Joint pain including any surgery and/or any Investigations in this section

13) Any other information you feel the instructor should be aware of

I declare I have read, understood and answered truthfully all of the questions listed in this document.

Signature

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Pilates Participation, Mat work and Reformer, Informed Consent Waiver:

The Pilates program will begin at a low level and will be advanced in stages depending on your fitness levels. It is important for you to realise that you are entitled to stop whenever you wish if you feel tired or are in any discomfort. There exists the possibility of certain dangers when exercising; abnormal blood pressure, fainting, irregular / fast or slow heart rhythm. Whilst every care will be taken to ensure your safety it is impossible to predict the body’s exact response to exercise. Therefore, it is important that you provide the correct information on the enrolment form to minimise any risk. It is essential that you make the instructor aware of any changes to your medication or health. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. It is recommended that you discuss with your GP or Health professional prior to commencing any new exercise programme and we recommend an assessment Olivia Bailey if you have an medical conditions. It is recommended to get clearance by your health practitioner before resuming exercise after birth.

With this knowledge, I confirm that I acknowledge that I am making a voluntary choice to participate and engage in the class/routine where I will receive information and instruction about Pilates, physical exercise and health. I understand that as I will be attending as part of a class and that the exercise program will not be specifically designed to my individual needs, although the class instructor will highlight any areas of personal weakness and suggest areas for self practice. I accept all and any risk associated with my decision to participate. I am fully aware that the class/routine requires physical exertion which may cause physical injury, I am fully aware of the risks and hazards involved. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation in these Pilates classes. I agree to work at my own level and inform the instructor of any problems during the session. I have read and understood all the information given to me and completed the registration form in full and consent to take part in a Pilates class run by OB Physiotherapy / Sports Therapy.

By booking this class with OB Physio Therapy/ Sports Therapy, I understand and agree that Olivia Bailey has no liability to me or my child or for any injury or loss you may suffer in connection with any Pilates session.

I understand that I am fully responsible for the supervision and care of my child(ren) that are present within my mum and baby pilates session.

The instructor can accept no liability for personal injury or damages related to the participation in a class if:

1) Your doctor has, on health grounds, advised you against such exercise.

2) You fail to observe instructions on safety of an exercise.

3) Injury is caused by the negligence of another participant in the class.

4) Misuse of any Equipment Classes may involve the use of equipment such as TheraBand, small balls, pilates circle or balance pads etc., this is optional and done at your own risk.

5) Exercise should be performed at a pace which feels comfortable for you. If you have any problems during the sessions, please let the instructor know immediately.

The use of any information provided by Olivia Bailey is solely at your own risk. I confirm agreement for my teacher to contact me with information on classes and other Pilates activities and relevant information through email and newsletter and understand that I have the right to withdraw this ‘consent to be contacted’ at any time. I confirm that I have read and understood the above advice and that the information. I voluntarily agree to the above liability waiver and terms and conditions under my own free will.

I am aware that classes are booked in blocks and payment is due at the time of booking to secure my place. Payment for classes is non-refundable but can be transferrable.

I confirm that I have read and understood the above advice and the information provided. I voluntarily agree to the above liability waiver and terms and conditions under my own free will.

I have read and agree to the terms and conditions

Signature

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