How to Book

Health Screening Questionnaire and Informed Consent

Class Venue*

Class Day and Time*

Your name*

Your email*

Your address*

Postcode*

Phone number*

Emergency Contact Name, Address & Telephone numbers*

What is your occupation?*

Age*
Under 2526-3536-4546-5556-6566-7575+

Please read the following questions carefully and answer each one as honestly as you can.

1) Are you on any medication that may affect you during the session?*
YesNo

If you answered YES please give details

2) Have you any illness/disabilities?*
YesNo

If you answered YES please give details

3) Do you have any injuries or joint problems?*
YesNo

If you answered YES please give details

4) Have you been recommended to Modern Pilates by a health/medical practitioner e.g. Physiotherapist?*
YesNo

If you answered YES please give details and contact numbers if possible

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

6) In brief please state:
(a) your exercise history (i.e. when you last exercised and what activity it was)

(b) what are you hoping to achieve from your class?

7) Are there any other conditions that your teacher should be aware of? If YES please give details and contact numbers if possible.

Where/how did you hear about this class?

Is there anything else you would like to share with us?

If you have answered YES to any of the above questions, we suggest you seek medical approval to continue with your training. Please feel free to mention anything else that I may need to know to keep your session safe both now and as the training progresses.

Whilst every effort is made to keep the session both safe and effective there is a risk of injury as with any programme of activity. I am participating of my own free will. On rare occasions there may be a stand in teacher. Please feel free to discuss any questions you may have regarding your Modern Pilates class.

Informed Consent

I hereby state that I have read, understood and answered honestly the pre-exercise health screening questionnaire. Any questions I had were answered to my full satisfaction. Whilst every effort is made to keep the class safe and enjoyable, I am participating of my own free will and as with any exercise programme there is a risk of injury. I understand that on rare occasions there may be a stand in teacher.

By submitting this form, you agree to the above information and have read and understood the Terms and Conditions.