Pregnant Form Update - Pilates Teacher Jess

Assessed by:

Date:

Client Name:

EMAIL:

Date:

Telephone:

Postcode:

Work:

Sex:

Male

Female

Address:

GP Name & Address:

Were you referred here by a medical/health practitioner?

If not, please state how you heard of us:

Obstetrician Name & Address:

Pilates Aims

Why have you decided to commence Pilates?

Core stability

Flexibility

Posture

Toning

Pelvic floor training

Relaxation

What are the three main aims that you are hoping to achieve with you Pilates program?

Lifestyle

Does your occupation involve any repetitive movements or prolonged postures? If yes, please briefly explain.

Are you involved with any other sports and/or hobbies? If yes, please briefly outline.

Are you currently working? If so what is your occupation?

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: Are you currently experiencing OR ever been diagnosed with any of the following conditions?

1	Back Pain	If yes, please give further detail	Yes	No
2	Back Pain	Plain at the front or back of your pelvis	Yes	No
3	Any other muscle or joint conditions	Plain at the front or back of your pelvis	Yes	No
4	Heart problems	Plain at the front or back of your pelvis	Yes	No
5	High or low blood pressure	Plain at the front or back of your pelvis	Yes	No
6	Circulatory problems e.g blood clots	Plain at the front or back of your pelvis	Yes	No
7	Diabetes	Plain at the front or back of your pelvis	Yes	No
8	Abnormal vaginal bleeding	Plain at the front or back of your pelvis	Yes	No
9	Pre-eclampsia	Plain at the front or back of your pelvis	Yes	No
10	Incompetent cervix	Plain at the front or back of your pelvis	Yes	No
11	History of spontaneous miscarriage	Plain at the front or back of your pelvis	Yes	No
12	Anaemia	Plain at the front or back of your pelvis	Yes	No
13	Epilepsy (Grand mal seizures)	Plain at the front or back of your pelvis	Yes	No
14	Abnormal placental function or position	Plain at the front or back of your pelvis	Yes	No

2: Is this your first pregnancy?

Yes

No

3: If no, how many other children do you have & what are their ages?

4: How many weeks pregnant are you?

5: Have you had any complications with your pregnancy? If yes, Please give details?

Yes

No

6: Have you ever had an episode of low back pain?

Yes

No

7: If yes, approx. how many previous episodes of low back pain have you had?

8: Have you had any recent injuries or surgery? Please give details.

Yes

No

9: Are you having twins?

Yes

No

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.

Signed:

Date:

Teacher Signature:

Date:

General Client Details

Pilates Aims

Lifestyle

Medical Questionnaire

PILATES PARTICIPATION INFORMED CONSENT