General Client Details

Pilates Aims

Lifestyle

Medical Questionnaire

If you have ticked any of the above boxes please contact Jessica before attending your session at pilatesteacherjess@gmail.com as she may need a medical professional letter.

1 Back Pain If yes, please give further detail
2 Back Pain Plain at the front or back of your pelvis
3 Any other muscle or joint conditions Plain at the front or back of your pelvis
4 Heart problems Plain at the front or back of your pelvis
5 High or low blood pressure Plain at the front or back of your pelvis
6 Circulatory problems e.g blood clots Plain at the front or back of your pelvis
7 Diabetes Plain at the front or back of your pelvis
8 Abnormal vaginal bleeding Plain at the front or back of your pelvis
9 Pre-eclampsia Plain at the front or back of your pelvis
10 Incompetent cervix Plain at the front or back of your pelvis
11 History of spontaneous miscarriage Plain at the front or back of your pelvis
12 Anaemia Plain at the front or back of your pelvis
13 Epilepsy (Grand mal seizures) Plain at the front or back of your pelvis
14 Abnormal placental function or position Plain at the front or back of your pelvis

PILATES PARTICIPATION INFORMED CONSENT

The Pilates program will begin at a low level and will be advanced in stages depending on your fitness level. Pilates sessions may be stopped because of signs of fatigue or strain. It is important for you 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 body's exact response to exercise. Efforts will be made to minimise these risks by evaluation of preliminary information relating to your health and by observations during exercising. Emergency equipment and trained personnel are available to deal with unusual situations that may arise.

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

Please note a full fee may be applicable if less than 24 hours notice is not given for all cancellations.