Physio Led Pilates

Venue Health Screening Form

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Have you done pilates before?

General health

How is your general health?

Medical history (do you have any of the following?)

Osteoporosis/Osteopenia
Nerve pain or sciatica
Joint pain or injuries
Recent illness/fever or infections
Awaiting or recently had surgery
Previous fractures
Chest/lung/breathing problems
Heart issues
Blood pressure issues
Previous blood clots/stroke/TIA/DVT
Circulatory issues
Diabetes or low blood sugar
Epilepsy
History of Cancer
Pain at night/difficulty settling
Night sweats
Unexplained weight loss
Rheumatoid arthritis/inflammatory conditions
Family history of Cancer/inflammatory conditions
Dizziness/fainting spells
Double vision
Problems with speech/swallowing
Balance issues
Neurological disorders
Pregnant/undergoing fertility treatment
Kidney disease/liver disease
Higher risk of infection (for any reason)
Compromised immune system
Do you take steroids or have you in the past year?

Would you find any of the following positions uncomfortable to be in during class? 

Lying on your front
Lying on your side
Lying on your back
Kneeling
Kneeling on your hands and knees

Disclaimer and consent

Please read this pilates participation informed consent thoroughly and sign below.

 

I have answered these questions to the best of my ability and will update my instructor of any changes to my health or if I become pregnant. I understand that my failure to give any updates on my health may pose a risk to my personal wellbeing at class.

All exercises will start at the beginners level and will build depending on your ability, health and control. It is important that you exercise to your own ability and comfort level. Whilst every care will be taken, there does exist the possibility of certain dangers when exercising and it is impossible to predict the exact response to exercise. Every effort will be made to minimise risk by evaluation of the health information you have given in this questionnaire. You understand that it is your responsibility to follow the teacher’s instructions and modifications in order to exercise safely. You also have the individual responsibility to stop any exercise because of signs of fatigue, excessive strain or discomfort or at any time you wish. Please also do let your class instructor know if you have experienced any problems during your class or have felt unwell or pain with any of the exercises.

 

No liability can be accepted if you are doing this type of exercise against the medical advice of a doctor or another health professional.

 

I have read and understood the Privacy Policy and Terms and Conditions of Booking.

I consent to completing the online COVID-19 Screening and Consent Form 24 hours prior to attending my first class. I understand that my failure to complete this form will result in me being unable to attend the class. By submitting this online health screening form, I thereby agree to all sections in this disclaimer.

Communicating with you

Thanks for submitting!

FOR INSTRUCTOR USE ONLY