PILATES CLASSES (PLEASE SELECT)

Modern Pilates at Cuddington and Sandiway Village Hall

AT-Pilates at The Studio, Tattenhall, 11.30am class; FULL on 3 March.

AT-Pilates at The Studio, Tattenhall, 12.45pm class, spaces 3 March.

HEALTH SCREENING QUESTIONNAIRE & INFORMED CONSENT.

PERSONAL INFORMATION

Please complete the document by filling in all of the fields and selecting YES and No where appropriate. Please type NA if the question is not relevant to you.

Name:

Phone:

Mobile:

Email:

Date of Birth:

Home Address:

Emergency contact number:

GP's name & address:

Where did you find out about Pilates classes with Wendy Broad?

Do you have any particular needs that it would be useful for us to know about e.g. restricted mobility (can you safely get down to the floor and lie on your back, front and side?, do you have hearing or visual impairment? Please provide relevant information

Would you like to join our mailing list? We may send you newsletters, marketing material or promotional info from time to time YesNo

OCCUPATION AND LIFESTYLE

Occupation:

1) Does your occupation or lifestyle require extended periods of sitting? YesNo

2) Do you participate in physical activity such as golf, swimming, walking? YesNo

3) Have you done any Pilates before? YesNo

HEALTH SCREENING QUESTIONNAIRE

If you are between ages 15 and 69, the health screening questionnaire will tell you if you should check with a doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, please check with your doctor first.

1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YesNo

2) Do you feel pain in your chest when you do physical activity? YesNo

3) In the past month, have you had a chest pain when you were not doing physical activity? YesNo

4) Do you lose balance because of dizziness or do you ever lose consciousness? YesNo

5) Do you have a bone or joint problem (for example arthritis, hypermobility, osteoporosis, slipped disc, joint replacement) YesNo

6) Do you suffer from lower back pain i.e chronic pain or numbness? YesNo

7) Is your doctor currently prescribing medication for your blood pressure or heart condition? YesNo

8) Are you pregnant or have you been pregnant in the last 6 months? YesNo

9)Do you know of any other reason why you should not take part in physical activity?YesNo

If you answered YES to one or more questions please give details:

IMPORTANT PLEASE READ THIS CAREFULLY

If you have answered YES to any of the above questions, you should consult with your doctor to clarify that it is safe to become physically active at this time. Please mention anything else that I may need to know to keep your session safe both now and in the future. Whilst every effort is made to keep the sessions both safe and effective, there is a risk of injury as with any programme of activity.

Please feel free to discuss any questions or queries you may have regarding your Modern Pilates or AT-Pilates classes. On rare occasions there may be a stand in teacher.

INFORMED CONSENT

I hereby state that I have read, understood and accurately completed this pre-exercise health screening questionnaire.

Whilst every effort is made to keep the class safe and enjoyable, I confirm that I am participating of my own free will and I acknowledge that as with any exercise programme there is a risk of injury.

Any questions that I had were answered to my full satisfaction.

I agree to follow the guidelines and instructions throughout the classes and work within my safe limits. I acknowledge that the exercises are progressive and I can choose to exercise at a lower level or to rest at any time.

I agree to inform the teacher if I am in pain or need help or need an alternative exercise at any time.

I understand that on rare occasions there may be a stand in teacher.

If I answered NO to all questions in the Health Screening Questionnaire, I acknowledge that I may participate in physical activity without consulting my doctor

If I answered YES to any questions in the Health Screening Questionnaire, I have sought medical advice and my doctor has agreed that I may exercise. Written permission is not required.

I agree to inform the teacher if my medical health status changes or any new health conditions arise.

Participant's Name:

Participant's Signature:

Date:

Data Protection Policy and Privacy Policy

Your data will be handled according to my data protection and privacy policy, which is available from my website Data Protection Policy and Privacy Policy.

The health information is collected for my insurance purposes with Holistic Insurance Services and to enable us to respond to your needs and assess for class suitability. Your personal contact details may be used by us to contact you about events and offers, if you give us permission to do so. Your contact details are not shared with third parties. A paper copy of your information is held in a locked cabinet for a period of 5 years as a condition of my insurance policy. After this time your information will be destroyed.