Livewell | General Pilates Screening

Session*

General Client Details

Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number*

Email*

GP Name and Address*

Where did you hear about Live Well Waterford? If you were recommeded to attend clinic/classes by a healthcare practitioner, please state their details:*

Medical Questionnaire

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

*

Lower back pain
Pelvic pain
Any other spinal condition
Any other oprthopaedic conditions
High or low blood pressure
Epilepsy (Grand mal seizures)
Heart problems
NONE OF THE ABOVE

Are you pregnant?*

If yes, how many weeks pregnant are you?*

Have you had any complications with your pregnancy?*

If yes, please specify*

Have you ever had an episode of Lower back pain?*

If yes how many previous episodes of Lower back pain have you had?*

Have you had any recent injuries or surgery?*

If yes, please provide details:*

Which, if any, of the following conditions have you been diagnosed with or had treatment for:*

If you have other health conditions you'd like to make known, please state them here:

Pilates Aims

Have you done pilates before?*

Why have you decided to commence pilates?*

What aspects of your health would you like to concentrate on?*

Core Stability
Flexibility
Posture
Pelvic Floor training
Toning
Relaxation

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

Pilates Participation Informed Consent

The Pilates programme will begin at a low level and will be advanced in stages depending on your fitness level. We may stop the exercise session because of signs of fatigue or excessive 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; 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. Every effort will be made to minimise these risks by evaluation of the preliminary information you provide in this form and by observations during exercise.

I understand I understand that the Pilates programme is specifically designed by the class instructor and will take into account details given in my health questionnaire. Therefore, this programme of exercise should only be undertaken in a Pilates class, or when I have been given specific instructions to exercise on my own.

Please note that refund payments will not be given for unattended classes.

THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 1984.

I have read and agree to terms*

Live Well Waterford

General Pilates Screening

General Pilates Screening

General Client Details

Medical Questionnaire

Pilates Aims

Pilates Participation Informed Consent

Classes

Treatments

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