At Home with Pilates
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At Home with Pilates
: Client Registration Form
All your information is treated in the strictest of confidence
*
Indicates required field
Name
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First
Last
Date of Birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Contact Telephone Number / Mobile Preferred
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Email (Your privacy is very important & your email will not be disclosed to third party companies)
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Occupation
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Sports, Hobbies
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Emergency Contact : Name & Phone Numbers
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Please ensure you have permission from your Emergency Contact to share their details with
At Home with
Pilates.
PART 1 - YOUR BACKGROUND AND YOUR HEALTH (please circle the answer(s) as appropriate)
1. DOES YOUR WORK/SPORT INVOLVE ANY OF THE FOLLOWING?
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Sitting for long periods
Driving
Bending
Standing
Heavy Lifting
Other repetitive action
2. WILL THIS BE THE FIRST TIME THAT YOU HAVE PRACTISED PILATES?
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Yes
No
IF NO, HAVE YOU PREVIOUSLY ATTENDED;
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Studio Pilates / Matwork Classes
Other Pilates Matwork Classes
At home Pilates (Dvd, book etc)
NUMBER OF CLASSES PREVIOUSLY ATTENDED
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0 - 5
5 - 10
10 - 20
20 +
3. HAS YOUR DOCTOR EVER SAID THAT YOU HAVE ANY SORT OF HEART TROUBLE OR DEFECT? Choose One
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Yes
No
4. DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU UNDERTAKE PHYSICAL ACTIVITY?
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Yes
No
5. ARE YOU OR COULD YOU BE PREGNANT NOW?
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Yes
No
If YES, when is your due date?
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6. HAVE YOU BEEN PREGNANT IN THE LAST SIX MONTHS?
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Yes
No
7. IF YOU HAVE HAD A BABY HOW WAS IT DELIVERED?
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Vaginal
Caesarean
Vaginal with intervention (e.g. Forceps)
8. DO YOU OFTEN GET HEADACHES?
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Yes
No
9. DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS, FEEL FAINT OR DIZZY?Choose One
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Yes
No
10. IS YOUR BLOOD PRESSURE (BP):
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High
Low
Normal
If your BP is regulated by medication. Please give details:
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11. HAVE YOU HAD MAJOR SURGERY IN THE LAST 10 YEARS?
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Yes
No
12. HAVE YOU HAD MINOR SURGERY IN THE LAST TWO YEARS?
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Yes
No
13. DO YOU HAVE ANY OF THE FOLLOWING?
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Asthma
Diabetes
Epilepsy
14. HAVE YOU EVER BEEN TOLD YOU HAVE ARTHRITIC JOINTS, OSTEOPOROSIS, OSTEOPENIA OR ANY BONE OR JOINT PROBLEM THAT MAY BE MADE WORSE BY EXERCISING?
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Yes
No
15. DO YOU SUFFER FROM BACK OR NECK PAIN?
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Yes
No
16. DO YOU HAVE PAIN OR RESTRICTED MOVEMENT IN ANY OTHER JOINTS (EG: HIP, KNEE, ANKLE, SHOULDER)?
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Yes
No
17. HAVE YOU EVER BEEN DIAGNOSED AS HYPERMOBILE (EXCESSIVE JOINT MOBILITY)?
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Yes
No
IF YOU HAVE ANSWERED 'YES' FOR QUESTIONS # 14-17, DO YOU HAVE MEDICAL PERMISSION TO EXERCISE?
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Yes
No
18. ARE THERE ANY MOVEMENTS THAT CAUSE YOU PAIN?
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Yes
No
19. ARE YOU TAKING ANY DRUGS OR MEDICATION WHICH MAY AFFECT YOUR ABILITY TO EXERCISE?
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Yes
No
20. DID A SPECIALIST PRACTITIONER (e.g. GP, Consultant, Osteopath, Physiotherapist) RECOMMEND YOU DO PILATES?
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Yes
No
21. DO YOU HEREBY GIVE ME PERMISSION TO CONTACT THEM?
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Yes
No
If so, please state their name and contact number
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Please insert below any health problems, not yet mentioned that may impact your ability to exercise.
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* VERY IMPORTANT * If you answered YES to any of questions 3 - 19 above, I advise you consult with your medical practitioner BEFORE STARTING PILATES classes. Please give further relevant details below, in confidence, to any questions you ticked YES.
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PART 2 - YOUR AIMS
WHAT ARE YOUR REASONS FOR TAKING UP PILATES?
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WHAT LONGER-TERM HEALTH OR PHYSCIAL GOALS WOULD YOU LIKE TO ACHIEVE OVER THE NEXT 3 - 12 MONTHS?
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PART 3 - IMPORTANT INFORMATION
Please advise Sally Eaves:
At Home with Pilates
before commencing any session if, for any reason, your health or your ability to exercise changes.
It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise
Pilates online live classes are very safe, but, as with all forms of physical exercise, it is sensible to consult with your GP before starting Pilates sessions
These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner
Sally Eaves:
At Home with Pilates
can accept no liability for personal injury related to participation in a session if;
Your Doctor has, on health grounds, advised you against such exercise
You fail to observe instructions on safety or technique
Such injury is caused by the negligence of another participant in the class
ALSO...
Exercise should be performed at a pace which feels comfortable to you
Pain is the body's warning system and should not be ignored!
Please inform Sally Eaves:
At Home with Pilates
immediately if you feel any discomfort during a session
Please also inform Sally Eaves:
At Home with Pilates
if you felt any discomfort following a previous session
I confirm that I have read and understood the above advice and all information I have given is correct.
I confirm that Sally Eaves:
At Home with Pilates
may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information;
will be used in confidence and stored securely and I have read and understand the
Privacy Statement
will not, in any circumstances, be shared with a third party without my written consent, unless that party is another Pilates teacher who will teach me
may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfill.
I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities and I understand that I have the right to withdraw this 'consent to be contacted' at any time.
Signed:
Client
*
Date
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Teacher to sign
*
Date
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Submit
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Pilates
Class Schedule
Pilates Foundations
Pilates for Stronger Bones
Registration Form
Contact
FAQs
Data Privacy