Name

Phone

Email Address

Date of Birth

Address

Sex Sex Male Female

Occupation

Sports / Hobbies

Emergency Contact Name

Emergency Contact Phone

Please indicate which class you would like as your 'Regular Weekly Class: day and time:

1. WILL THIS BE THE FIRST TIME THAT YOU HAVE PRACTISED PILATES? 1. WILL THIS BE THE FIRST TIME THAT YOU HAVE PRACTISED PILATES? Yes No

1.1 If NO, have you previously attended: 1.1 If NO, have you previously attended: Studio Body Control Pilates Matwork classes Other Pilates matwork At home (book, DVD)

1.2 If NO, what number of classes did you attend previously: 1.2 If NO, what number of classes did you attend previously: 0 - 5 5 - 10 10 - 20 20+

2. DOES YOUR WORK/SPORT INVOLVE ANY OF THE FOLLOWING? 2. DOES YOUR WORK/SPORT INVOLVE ANY OF THE FOLLOWING? Sitting for long periods Bending Lifting heavy weights Driving Standing Any other repetitive action

3. HAS YOUR DOCTOR EVER SAID THAT YOU HAVE ANY SORT OF HEART TROUBLE OR DEFECT? 3. HAS YOUR DOCTOR EVER SAID THAT YOU HAVE ANY SORT OF HEART TROUBLE OR DEFECT? Yes No

4. DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU UNDERTAKE PHYSICAL ACTIVITY? 4. DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU UNDERTAKE PHYSICAL ACTIVITY? Yes No

5. ARE YOU, OR COULD YOU BE PREGNANT NOW 5. ARE YOU, OR COULD YOU BE PREGNANT NOW Yes No

6. IF YOU HAVE HAD A BABY/BABIES PLEASE ADVISE WHETHER NATURAL OR C-SECTION AND THE DATE OF BIRTH 6. IF YOU HAVE HAD A BABY/BABIES PLEASE ADVISE WHETHER NATURAL OR C-SECTION AND THE DATE OF BIRTH Natural C-Section

Date of birth

7. DO YOU OFTEN GET HEADACHES? 7. DO YOU OFTEN GET HEADACHES? Yes No

8. DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS, FEEL FAINT OR DIZZY? 8. DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS, FEEL FAINT OR DIZZY? Yes No

9. HAVE YOU EVER BEEN DIAGNOSED WITH HIGH OR LOW BLOOD PRESSURE OR ARE YOU TAKING ANY FORM OF ANTIHYPERTENSIVE MEDICATION? 9. HAVE YOU EVER BEEN DIAGNOSED WITH HIGH OR LOW BLOOD PRESSURE OR ARE YOU TAKING ANY FORM OF ANTIHYPERTENSIVE MEDICATION? Yes No

10. HAVE YOU HAD MAJOR SURGERY IN THE LAST 10 YEARS? 10. HAVE YOU HAD MAJOR SURGERY IN THE LAST 10 YEARS? Yes No

11. HAVE YOU HAD MINOR SURGERY IN THE LAST TWO YEARS? 11. HAVE YOU HAD MINOR SURGERY IN THE LAST TWO YEARS? Yes No

12. DO YOU SUFFER FROM ASTHMA, DIABETES OR EPILEPSY? 12. DO YOU SUFFER FROM ASTHMA, DIABETES OR EPILEPSY? Yes No

13. HAVE YOU EVER BEEN TOLD YOU HAVE ARTHRITIC JOINTS OR ANY BONE OR JOINT PROBLEM THAT MAY BE MADE WORSE BY EXERCISING? 13. HAVE YOU EVER BEEN TOLD YOU HAVE ARTHRITIC JOINTS OR ANY BONE OR JOINT PROBLEM THAT MAY BE MADE WORSE BY EXERCISING? Yes No

13.1 If Yes please give more details here....

14. HAVE YOU EVER BEEN TOLD YOU HAVE OSTEOPOROSIS, OSTEOPENIA? 14. HAVE YOU EVER BEEN TOLD YOU HAVE OSTEOPOROSIS, OSTEOPENIA? Yes No

14.1, if Yes please give details of where and DEXA scan results if known:

15. DO YOU SUFFER FROM BACK OR NECK PAIN? 15. DO YOU SUFFER FROM BACK OR NECK PAIN? Yes No

15.1. If you have answered yes, please give more information and provide details of any diagnosis and/or further investigations you have had ie., MRI's, X-rays etc.

16. DO YOU HAVE PAIN OR RESTRICTED MOVEMENT IN ANY OTHER JOINTS (EG: HIP, KNEE, ANKLE, SHOULDER) OR any movement that causes you pain? 16. DO YOU HAVE PAIN OR RESTRICTED MOVEMENT IN ANY OTHER JOINTS (EG: HIP, KNEE, ANKLE, SHOULDER) OR any movement that causes you pain? Yes No

16.1 If yes please describe and rate pain on a scale of 1-10 (10 being the worst)

17. HAVE YOU EVER BEEN DIAGNOSED AS HYPERMOBILE (EXCESSIVE JOINT MOBILITY)? 17. HAVE YOU EVER BEEN DIAGNOSED AS HYPERMOBILE (EXCESSIVE JOINT MOBILITY)? Yes No

18. IF YOU HAVE ANSWERED ‘YES’ FOR QUESTIONS 12-17, DO YOU HAVE MEDICAL PERMISSION TO EXERCISE? 18. IF YOU HAVE ANSWERED ‘YES’ FOR QUESTIONS 12-17, DO YOU HAVE MEDICAL PERMISSION TO EXERCISE? Yes No

IF YOU HAVE ANSWERED 'YES' TO ANY OF THE ABOVE QUESTIONS IN THIS FORM AND NOT YET PROVIDED FURTHER DETAILS, PLEASE DO SO HERE:

19. WHAT ARE YOUR REASONS FOR TAKING UP PILATES?

20. WHAT HEALTH OR PHYSICAL GOALS WOULD YOU LIKE TO ACHIEVE OVER THE NEXT THREE MONTHS?

A. Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes A. Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes I understand

B. Exercise should be performed at a pace which feels comfortable for you. Pain is the body’s warning system and should not be ignored. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session. B. Exercise should be performed at a pace which feels comfortable for you. Pain is the body’s warning system and should not be ignored. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session. I understand

C. Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions. These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. The teacher can accept no liability for personal injury related to participation in a session if: • Your doctor has, on health grounds, advised you against such exercise • You fail to observe instructions on safety or technique • Such injury is caused by the negligence of another participant in the class/studio C. Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions. These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. The teacher can accept no liability for personal injury related to participation in a session if: • Your doctor has, on health grounds, advised you against such exercise • You fail to observe instructions on safety or technique • Such injury is caused by the negligence of another participant in the class/studio I understand

I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information: • will be used in confidence and stored securely • will not, in any circumstances, be shared with a third party without my written consent, unless that party is another (Body Control) Pilates teacher who will teach me • may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfill. I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information: • will be used in confidence and stored securely • will not, in any circumstances, be shared with a third party without my written consent, unless that party is another (Body Control) Pilates teacher who will teach me • may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfill. Yes

I confirm that I have read and understood the above advice and that the information I have given is correct. I confirm that I have read and understood the above advice and that the information I have given is correct. Yes

I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time. I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time. Yes

Signed (your name)

Date ( DD/MM/YYYY )