Your Name
*
First Name
Last Name
Proposed Start Date
MM
DD
YYYY
Email Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone / Mobile
*
(###)
###
####
Emergency Contact Name
*
First Name
Last Name
Relationship To You
*
Emergency Phone / Mobile
*
(###)
###
####
Do you have any immediate physical problems/issues that should be taken into consideration before commencing your exercise programme?
Do you have any fitness goals? If so, what are they?
If you answered Yes to the question above, please specify type and location:
Have you ever been advised to avoid physical activity?
(Please provide further details below)
Do you have any existing medical conditions that may be affected by exercise?
(for 'Pregnancy Related Questions' see below)
Do you smoke?
*
Yes
Occasionally
No
Please rate your overall health condition:
*
Excellent
Good
Fair
Poor
Do you suffer from any of the following conditions?
*
Please only tick the box if answering Yes.
If you answered Yes to any of the above, or have a condition not mentioned above
Please provide further information below:
Do you suffer from any of the following problems?
*
If you answered Yes to any of the above
Please provide further information below:
Are you currently pregnant?
*
N/A
Yes
No
If Yes, has your Midwife or other Medical professional given you the all clear to participate in physical activity?
N/A
Yes
No
Have you ever given birth?
N/A
Yes, within the last six months
Yes, within the last year
Yes, if more than a year ago
No
Have you experienced pregnancy related muscle/joint problems?
N/A
Yes
No
If you answered Yes to the question above, please specify:
(To the best of your knowledge)
Is there anything else you can think of that may affect you attending Pilates sessions?
Please acknowledge the statement below:
*
You intend to participate in a fitness programme facilitated by Sophie Snow Arnold (T/A Mineral Pilates & Wellbeing), as such acknowledge that the programme will require physical exertion. Although the most common injuries or symptoms associated with strenuous exercise involve sprains, strains, dizziness, fainting and/or discomfort in breathing, you recognise that there is a risk of injury (and in extreme cases, death) associated with any fitness programme. Consequently, you fully understand you should obtain the approval of your doctor before beginning any fitness programme, and have had the opportunity to do so. Before beginning the proposed programme, you acknowledge that Sophie Snow Arnold (T/A Mineral Pilates & Wellbeing) had asked you to advise them of any physical or mental limitations, whether you are taking any medications, as well as receiving any medical treatment that might make it unsafe for you to participate in the proposed fitness programme. You also acknowledge that there is no such limitation, medication or medical treatment other than those already disclosed on this form. Finally, you fully understand that, by ticking the box below you are agreeing not to hold Sophie Snow Arnold (T/A Mineral Pilates & Wellbeing) responsible for any bodily injury or property damage sustained during your participation in the proposed fitness programme. As such, you fully understand and agree that Sophie Snow Arnold (T/A Mineral Pilates & Wellbeing) shall not be liable for any bodily injury or property damage that may result either directly or indirectly from my participation in a fitness programme.
