Modified Pilates Registration Form

STRICTLY PRIVATE AND CONFIDENTIAL

Title

First Name

Surname

D.O.B

Address

Postcode

Telephone Number

Email Address

GP / Consultant

GP / Consultant Address

Emergency Contact Name

Emergency Contact No

Modified Pilates Aims

Why have you decided to commence / continue with Modified Pilates

Can you tell us about 3 day to day practical activities that you would like to improve on as a result of doing Modified Pilates? For example: Gardening, able to walk further etc.

Office use only: (Review of goals / progress after 12 months)

Health Questionnaire

AT THE PRESENT TIME - Are you experiencing any of the following conditions? *

If you have any of the above conditions please provide details

General Medical Questions

Are you pregnant?

YesNo

If yes, how many weeks pregnant are you?

Have you ever had any complications with your pregnancy / pregnancies?

YesNo

If yes, please provide further details

Have you ever had an episode of Low Back Pain

YesNo

If yes, how many previous episodes of low back pain have you had?

Are you waiting to see or currently seeing your G.P / Specialist Doctor or another healthcare specialist?

YesNo

If yes, please provide details

If you have selected any of the above conditions please provide further details

Are you taking any medication?

YesNo

If yes, please give further details

Lifestyle

What is your occupation or are you retired?

Does your occupation or lifestyle involve any repetitive movements or prolonged postures?

YesNo

If yes, please briefly explain

What other sports and / or hobbies are you involved in?

For your information

Please wear clothes that can you can move freely in. Please wear socks to the class. We have Pilates socks, Pilates pillows and a range of other Pilates small equipment available to buy in the clinic if you wish to purchase your own equipment for use in the class or at home.

Modified Pilates Participation Informed Consent

The Modified Pilates programme will begin at a low level and will be advanced in stages depending on your fitness level. We stop the exercise session because of signs of fatigue or excessive strain. It is important to realise that you may stop when you wish because of feelings of fatigue or any other discomfort.

There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the bodies exact response to exercise. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during exerciseing. Emergency equipment and trained personnel are available to deal with unusual situations that may arise.

I understand that with certain conditions a certain degree of undressing may be required during the assessment and the Modified Pilates instructor will explain this to me at the time. I understand the Modified Pilates programme will be specifically designed as a personal training plan and will take into account details given by my health questionnaire and assessment. Therefore, this programme of exercise should only be undertaken when in a Modified Pilates class, or when I have been give specific instructions to exercise on my own.

THIS INFORMATION IS PROTECTED BY GENERAL DATA PROTECTION REGULATION

Signed *

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Date *

For Official use only: Physio Comments

Physiotherapist Signature

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Date

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