Name
(no spaces between numbers please)
(no spaces between numbers please)
Have you done Pilates before?
How did you hear about us?
What aspect of your health would you like to focus on?
Lifestyle
Are you currently experiencing any of the following conditions?
Pregnancy
Are you pregnant?
Have you had any complications with your pregnancy?
What type of complications with your pregnancy have you had?
Have you had an episode of lower back pain?
Other Medical Conditions
Have you had any recent injuries or surgery?
Tick any of the following conditions that you have been diagnosed with or have had treatment for:
Private and Confidential
I declare that I have read the Medical Questionnaire and have completed it to the best of my knowledge. I understand that the Pilates program will begin at a low level and will be advanced in stages depending on my fitness level. I understand and agree that the therapist/instructor or I can stop the exercise session at any time if I am experiencing any symptoms of fatigue or discomfort or at risk of injury. I understand that there is a risk associated with undertaking any exercise program. I understand (a) whilst every care will be taken it is impossible to predict the body’s exact response to exercise and (b) every effort will be made to minimise these risks by evaluation of preliminary information relating to the questionnaire and by observation fitness and technique during exercise. For one to one sessions: I understand that the Pilates program will be specifically designed as a personal training plan and will take into account details about me given in my questionnaire and on initial assessment. I understand that this program of exercise should only be undertaken when I have been given specific instructions to exercise on my own. For class sessions: I understand that the Pilates program is designed for a general group and not specifically designed as a personal Pilates plan. Therefore I understand that the program of exercises should only be undertaken in a supervised Pilates class. Further I understand and agree that if I perform any of the exercises outside the class then I do so at my own risk. I agree that New You Pilates Pilates and Instructors, shall not be liable for injuries I suffer in respect of: 1. Pilates exercises I perform outside of a supervised Pilates session. 2. Pilates exercises performed other than in accordance with the direction and instructions of the instructor. 3. Undertaking Pilates exercises while suffering from an injury or ailment of which I have not informed New You Pilates or the instructor. 4. Mishap or injury inflicted by other participants of the Pilates group. 5. Any injury sustained while on the premises resulting from personal inattentiveness