Studio Pilates Health Screening Form Studio Pilates Health Screening Form Step 1 of 4 25% 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. About youYour main contact detailsName* First Last Address* Street Address Address Line 2 Town/City Post Code Mobile Phone NumberEmail* OccupationDate of Birth* Emergency ContactPlease provide the name, phone numbers and relationship to you of someone we may contact in case of an emergencyEmergency Contact*Name, number and relationship to you: Your Aims and ObjectivesKnowing what you would like helps us to serve you betterWhat brought you to Pilates with us?*How do you spend most of your day? Eg, working, retired, hobbies?Have you been a regular exerciser in the last 3 years? If YES, please give details below:Have you tried Pilates in the past, either matwork or studio equipment? If YES, please give details below:Out of everything that might be happening to you right now, which one thing would you REALLY like help with? Please give details below:* Health and Lifestyle QuestionsPlease answer in as much detail as possible. The more we know, the better we can help.Are you or could be pregnant or post natal of up to 6 months?*If YES, please give more details in the box across:YESNOPregnant / Post NatalDo you, or have you in the past had heart or cardiovascular problems*If YES, please give more details in the box across:YESNOCardiovascular Problems:Do you, or have you in the past had circulatory problems, e.g. high / low blood pressure*If YES, please give more details in the box across:YESNOCirculatory Problems:Do you feel pain in your chest when you do physical activity?*If YES, please give more details in the box across:YESNOChest Pain and Physical Activity:Do you have Asthma or have any Allergies?*If YES, please give more details in the box across:YESNOAsthma or Allergies:Please let me know if you use an inhaler (or other respiratory medication) or use antihistamines. Do you often feel faint or dizzy and if so, is it made worse by exercise*If YES, please give more details in the box across:YESNOFaint or Dizzy made worse by Exercise?Do you suffer from epilepsy or have had any seizures in your lifetime?*If YES, please give more details in the box across:YESNOEpilepsy or SeizuresDo you have Diabetes? IF YES, is it Type I or Type II?*If YES, please give more details in the box across:YESNODiabetes - Type I or Type IIDo you have arthritis? Is it Rheumatoid or Oesteo?*If YES, please give more details in the box across:YESNOArthritis - Rheumatoid or Oesteo (if you're not sure we can talk more later)Do your have, or is there a history of oesteoporosis or oesteopenia in your family?*If YES, please give more details in the box across:YESNOOesteoporosis or Oesteopenia:Have you had any broken bones, or any major trauma/surgeries/illnesses in the last 3 years?*If YES, please give more details in the box across:YESNOBroken bones, trauma, surgeries or illnesses:Do you have joint pain, movement restriction or wide-spread chronic pain?*If YES, please give more details in the box across:YESNOJoint pain, movement restrictions or widespread chronic pain:Are you currently seeing an NHS or Private Physiotherapist, Chiropractor, Oestopath or Medical Doctor? If YES please say what treatment you are receiving?*If YES, please give more details in the box across:YESNONHS or Private Physiotherapist, Chiropractor, Oestopath or Medical Doctor:Are you currently seeing ananyone for Complementary Therapy (EG: Reflexology, Massage, Reiki, etc? If YES please say what treatment you are receiving?*If YES, please give more details in the box across:YESNOComplementary Therapy:Are you on any medication? If you have a list, please bring it with you to your first appointment*If YES, please give more details in the box across:YESNOMedication:Is there anything else we need to know, but not yet mentioned?*Use this for information about your mobility, hearing/eyesight or anything else you think would be help for us to know.YESNOAnything else?: Health Screening DeclarationIt is important that everything we need to know about you is on this form. If you would like to talk to us personally, please call Cath on 0794 1012305, where she will be able to help you.Please read, enter your name and date in the box below and then press SUBMIT button. By pressing the SUBMIT button your are electronically acknowledging that all the information is true and correct at the submission date. Further updates of your health can be communicated to your teacher as and when it is necessary.*I have answered all questions to the best of my knowledge and belief and know of no other reason why I should not undertake a course of exercise. I will immediately inform the Pilates teacher if my medical condition changes in the future or if I am advised by my medical practitioner or other remedial therapist that I should refrain from exercise or particular movement patterns. I will immediately inform the Pilates teacher if I become pregnant, or suspect I may be pregnant. I understand that all exercise carries a risk of injury. I accept responsibility for my own body and own safety and acknowledge that I participate in this physical activity at my own risk and will stop exercising should I need to. I understand that I am free to choose not to participate in any prescribed exercise or activity throughout the session. The Pilates teacher may offer me professional advice and guidance relating to my ability to exercise and I accept that she may decide that it is unsafe to continue teaching me if I do not wish to follow that advice. The Pilates teacher may recommend that she contacts my GP or other appropriate health care professionals (NHS or Private) to discuss treatment, scans or test results relating to my physical activity and I understand that she will obtain my permission before making contact. Pilates exercises are not a substitute to medical treatment or counselling and I will refer back to my medical practitioner regarding any existing treatment programmes. In the event of an emergency, I authorise you to contact my emergency contact who is aware that you may do so. All information contained in this form is used solely for assessing suitability for exercise and for guiding the prescription of an exercise program. This information will be held securely and will not be passed on to any other party. PhoneThis field is for validation purposes and should be left unchanged.