Janet Butler Pilates with Make 2nds Count Health Screening Questionnaire & Informed Consent

Name

Address

Date of Birth

Occupation

Telephone

Did you join any of our previous Pilates exercise sessions?

Yes

If you answered No to the above question, please complete the form in full.

If you answered Yes to the above question, have there been any changes to your health since the last form you completed for Janet? If yes, please complete the form in full again.

Please confirm there have been no changes to your health since completing the last form by confirming today's date in the box below.

Please just complete the informed consent section at the bottom of the form.

Thank you.

Are you on medication that may affect you during the session?

Yes

If YES, please give details:

Have you any back or joint problems, disabilities or injuries?

Yes

If YES, please give details:

Are there any other conditions your teacher should be aware of or anything that may affect your ability to exercise?

Yes

If YES, please give details:

Have you been recommended to Clinical Pilates by a Health or medical practitioner e.g. doctor or physiotherapis?

Yes

If YES, please give details:

Are you pregnant or have been in the last 6 months?

Yes

If YES, please give details:

Please state your exercise history (current and past):

What are you hoping to achieve from Pilates?

Please note:

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 progress

Do you wish to mention anything else?

Informed Consent

I hereby state I have read, understood and answered honestly the pre-exercise health screening questionnaire.

Yes