top of page

REFORMER LOUNGE


ALL INFORMATION WILL BE TREATED IN THE STRICTEST OF CONFIDENCE

Birthday
Day
Month
Year

EMERGENCY CONTACT DETAILS

Do you give permission for us to contact your Doctor / medical practitioner?
Please tick the method of delivery for your most recent delivery.
If you had a vaginal delivery, did you have stitches to repair an episiotomy or tear?
If Yes, has it healed?
Have you ever experienced any of the following, past or present?
Have you ever suffered with pelvic girdle pain? Eg symphysis Pubis dysfunction, Sacroiliac joint pain
Do you lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy?
Is your blood pressure
Have you had major surgery in the last 10 years? (except Caesarean section)
Have you had minor surgery in the last two years?
Have you ever been told that you have arthritic joints, Osteoporosis or any bone or joint problem that may affect your ability to exercise?
Do you have neck or back pain?
Do you have pain or restricted movement in any other joints? (Eg Hips, Knee, Ankle, Shoulder?)
Are there any movements or positions which cause you pain?
Is there anything else in your medical history that you feel could affect your ability to exercise?
Are you taking any medications that may affect your ability to exercise?
Are you breastfeeding?
Has your Doctor, consultant or midwife given you medical clearance to take part in exercise?
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

IMPORTANT INFORMATION


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


If you are pregnant, we strongly recommend that you check with your doctor/midwife at regular intervals (perhaps at your antenatal check ups) if it is still ok for you to exercise.


If you are in doubt about the suitability of the exercises, please 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 not given you medical clearance to exercise/to continue to exercise.

  • You fail to observe instructions on safety and technique.

  • Such injury is caused by the negligence of another participant in the class/studio.

The exercises, and the transitions between exercises, should be performed at a pace which feels comfortable to you.


Please tell the teacher if you feel any discomfort, dizziness, nausea or pain during the session.


Please also inform the teacher if you felt discomfort or pain after a previous session.


I understand that Pilates Reformer exercises involve hands-on corrections and I hereby consent for my teachers to work in this way.


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


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 third party without my written consent, unless that party is another 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 fulfil. 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.



Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Day
Month
Year
bottom of page