Enrolment Form - Wellness With Jo

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Enrolment Form

Name
First Last
Date Of Birth
DD slash MM slash YYYY
Phone Number
Email Address
Emergency Contact Name
Emergency Contact Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Aims
Have you ever done pilates before?
- Yes
- No
Why have you decided to commence Clinical Pilates?
Which aspect of your health and well-being would you like to concentrate on?
- Core stability
- Strength
- Flexibility
- Improving aches/pains
- Stress
- Relief/Relaxation
- Posture
- Sports
Lifestyle
What is your occupation?
Does your job/lifestyle include any of these?
- Sitting for long periods
- Driving
- Bending
- Prolonged standing
- Lifting
- Repetitive movements
What sports/activities are you involved with?
Health Questionnaire
Are you currently experiencing or have you been diagnosed by the doctor with any of the following?
CTRL click to select multiple options
Are you pregnant?
- Yes
- No
How many weeks?
Have you had previous pregnancies in last 6 months?
- Yes
- No
Is there a specific movement or position which causes you pain?
If you have had neck or back pain, when was your most recent episode?
How many previous episodes of neck/back pain and what treatment have you received?
Have you had any recent fractures or injuries? (State when and where)
Have you had any recent surgery? (State when and what type)
Are you taking any medication currently? (If so please list)
Informed Consent
Pilates exercises are essentially very safe however there exists a minor possibility of certain dangers when exercising. While every care is taken to minimise these risks by evaluating the information you have provided in this form, predicting the exact response to exercise is impossible. The classes are not a substitute for medical treatment and it is wise to consult your doctor before starting the classes if you do not take regular exercise. The instructor can accept no liability for personal injury related to class participation if: A) Your doctor has, on health grounds, advised you against such exercise. B) You fail to observe instructions on safety or technique. C) Such injury is caused by the negligence of another participant in the class.
- I understand that the Pilates program will begin at a low level and be advanced according to levels of ability or fitness. The exercises may be stopped in the case of fatigue or discomfort.
- I agree to inform my instructor before any session if for any reason my health or ability to exercise has changed.
Name
First Last
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Get in touch

For more information or to book an appointment or Clinical Pilates course, please get in touch using the options below.

mail@wellnesswithjo.co.uk

Address

Twyford

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