Pilates Application Form

							                                    Belper Rehab Physio
                             Physiotherapy & Sports Injury Clinic

                              Pilates Course Application Form

Course Title:

Dates:

 GENERAL CLIENT DETAILS
Name:

Address:



Post Code:

Tel: H:                                 M:                             W:

 HEALTH QUESTIONNAIRE

    1) Are you suffering from any of the following conditions?

Low Back Pain                                                                   Yes   No
Pelvic Pain                                                                     Yes   No
Any other spinal condition                                                      Yes   No
Any other orthopaedic condition/ injury                                         Yes   No
Heart problems                                                                  Yes   No
High or Low Blood Pressure                                                      Yes   No
Epilepsy                                                                        Yes   No
If answered Yes to any of the above please provide further info on a separate sheet
including diagnosis, treatment, previous physiotherapy input/advice.


2) Are you pregnant or post natal? If Yes how many weeks are you?               Yes   No

3) a) Have you ever had an episode of low back/neck pain Yes             No

  b) If Yes how many episodes have you had and when was the last flare-up?

4) Have you had any recent injuries or surgery? If Yes please give details. Yes        No

5) Circle any of the following conditions that you have been diagnosed with or have had
   treatment for:

Asthma          Arthritis      Stroke         Diabetes           Osteoporosis

Depression      Bronchitis     Cancer         Dermatitis

(Please provide further information on the condition and your current medications)
        6) Please provide your height and weight (needed to ensure correct gym ball size)

        Height………………………………….Weight…………………………….

        7) Will you be bringing your own gym ball to the class?        Yes              No

Pilates Participation Informed Consent:

I can confirm I have provided all relevant information regarding my health status and that Belper Rehab Physio
will not be held responsible for any injury occurring during or as a result of the class. I understand that 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. Every effort will be
made to minimise these risks by the evaluation of preliminary information relating to your health and fitness
and by observations during exercise.

I understand that I must stop exercising and inform the instructor if I feel unwell. I am aware that there are
risks of exercising using a gym ball and Pilates ball which include falls due to the unstable nature of the
exercise. Gym balls on rare occasions may deflate or burst and I understand I am exercising at my own risk
with a gym ball. I understand that there is a risk using therabands/exercise bands such as breakage or eye
injury and I use these at my own risk and understand that it is not compulsory to use them within the class.

I understand that a prerequisite to the equipment classes is basic level of Pilates and I must have attended
classes/teaching recently to ensure I have a good base level of core stability fitness and awareness of the
Pilates core activation method.

Signed……………………………………………………Print……………………………………………Date…………………………………
Terms & Conditions:

The course must be paid for in full no later than 1 week prior to the class commencement. This is non-
refundable in all circumstances. If you miss a session this cannot be made up at any other time.



Payment:

Course cost is £

Circle payment method

         Cheque:        Payable to Ruth Machej
         Cash:          Payment on attendance £ per session

    Payment can be given to me in person or leave in an envelope at the Fit Pit Gym with John or Ann Stone
    addressed to Ruth Machej, Belper Rehab Physio.

    Cheques can be posted to Ruth Machej, Belper Rehab Physio, The Fit Pit Gym, East Mill, Bridgefoot, Belper.
    DE56 1XX.
     Administration only:

        Payment received:     Yes     Payment type: Cash / Cheque

                              No