Please complete this form after confirming your place on a course.
Where did you find out about us?
Have you ever had any of the following treatments?
1) Have you ever had any of the following?
If you have indicated any of the above, please give further details here:
2) Please give date of birth and method of delivery for all children:
3) Have you ever had any surgery other than caesarean?
If yes, please give further details including dates (approx.)
Type of Surgery:
4) Please list any current medication:
5) Have you had any accidents/injuries in the past?
If yes, please give further details:
6) Are you currently suffering from pain or injury?
How many weeks post natal will you be when you start pilates?
Did you have stitches to repair an episiotomy or tear?
If yes, have you healed?
Have you noticed any weakness in your pelvic floor?
Are you breastfeeding?
Do you have any worries or concerns about exercising whilst pregnant or post natal?
Has your doctor or consultant or midwife given you medical clearance to take part in exercise?
Are there any movements that cause you pain or restriction?
What health or physical goals would you like to achieve over the next few months?
If you have answered yes to any of the medical questions, we advise you consult with your medical practitioner before you start Pilates Classes. The therapist/teacher can accept no liability for personal injury if your doctor has, on health grounds advised you against such exercise, or if you fail to observe instructions on safety or technique, or if such injury is caused by the negligence of another participant in the class. Exercise should be performed at a pace which feels comfortable for you, please inform your teacher if you feel any discomfort during a session or after a previous session.
I declare that all information given on this form is true and correct to the best of my knowledge. I understand and consent to undergo Massage treatments and/or Pilates, based on the explanation I have received about this, and the medical information I have provided above. I understand that it is my responsibility to inform the therapist/teacher of any changes to the information given. If enrolling for Pilates I confirm that I have had medical clearance to exercise. I understand that Body Control Pilates and STOTT Pilates exercises involve hands-on correction and I hereby consent for my teachers to work in this way.
I also confirm that my teacher/therapist may use the contents of this form and any other information I may later provide, for teaching or massage therapy purposes, and that this information will be used in confidence and stored securely and will not in any circumstances be shared with a third party without my written consent, other than employees of Upminster Sports Massage & Pilates. This form may be retained by the teacher/therapist for a period of time such as complies with professional, legal and insurance requirements that they must fulfil. I confirm agreement for Upminster Sports Massage & Pilates to contact me with information on Pilates classes and other Pilates or Sports Massage related activities, and understand that I have the right to withdraw this 'consent to be contacted' at any time.
Please enter your full name and today's date into the boxes below.