Health Screening Form - Pelvic Health Step 1 of 3 33% Diamond Pilates - Health Screening FormIt is vital we know a bit more about you, your goals and your current and previous medical history. It helps us decide on the best options for you and your body, so you get the best results. The more we know about you now, the more time we have for your first session. Please answer each questions as honestly and completely as possible. Please be as honest and candid as you can; all information is treated in the strictest of confidence.All About YouYour main contact details.Name First Last Mobile PhoneEmail Address Street Address Address Line 2 City/Town County Post Code Date of Birth Date Format: DD slash MM slash YYYY OccupationHow do you spend most of your day?AgePlease choose an age range. Under 30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 Over 80 Session ParticipationExercise is a healthy was of getting more active and fitter, it is an ideal form of exercise for posture and rehabilitation. Diamond Pilates teachers are trained to deal with pelvic floor issues. However, you are participating of your own free will and see no reason why you should not participate in the sessions. Should you have any concerns, defer your class and seek medical advice before you start. If you are over 69 and not used to activity, we suggest you consult your Doctor before starting your classes. Please read the questions carefully and answer them to be the best of your knowledge.1. Has your Doctor ever said that you have a heart condition or any other medical condition and advised you against exercise?*YesNo2. Do you feel pain in your chest when you do physical activity?*YesNo3. In the past month, have you had chest pain when you were not doing physical activty?*YesNo4. Do you lose your balance because of dizziness or do you ever lose consciousness?*YesNoYou need to speak to your Doctor, if...you have answered YES to one of the above questions. Tell your Doctor about the PAR-Q and to which questions you answered yes.Have you any illness/disabilities/conditions that may affect you during these sessions?*YesNoIf YES, please give more details.Are you pregnant or recently had a baby?*YesNoDo you have any injuries, joint problems or back issues?*YesNoIf YES, please give more details.Do you have any issues with stress incontinence?*YesNoPlease discuss in confidence with your Diamond Pilates TutorDo you have a vaginal or rectal prolapse?*YesNoPlease discuss in confidence with your Diamond Pilates TutorDo you wish to work on your pelvic floor muscles or have any other issues you wish to discuss?*YesNoPlease discuss in confidence with your Diamond Pilates TutorPlease note any problems you feel may affect your participation in this class.EG, can you get up and down from the floor? Can you kneel?Have you been recommended by a Physiotherapist or health professional?*YesNoPlease discuss in confidence with your Diamond Pilates TutorPlease give details if you have answered YES. Informed ConsentWhilst every effort is made to keep the session both safe and effective there is a risk of injury with any programme of activity. Please inform your instructor and change your PAR-Q if you have any changes or have an injury.I am participating in this session of my own free will. On rare occasions, there maybe a stand-in teacher. Feel free to discuss any questions you may have regarding your exercise class. This class is not aimed at clients with Cardio Respiratory issues. I have read, understood and completed this questionnaire to best of my ability and current knowledge. Any questions I had have been answered to my full satisfaction.Client SignatureBy typing your name below, you are electronically signing the form.CommentsThis field is for validation purposes and should be left unchanged.