Assessment form

CLIENT CONFIDENTIAL

Personal Details (Please complete the form as fully as possible)
Please print out this form, fill it in and send in the post to me with your payment and Booking form

Name .............................................		Date of Birth.........................................................
Address...........................................		Sex ......................................	Male / Female
.......................................................		Occupation ...........................................................................
......................................................		Sports/hobbies ...................................................................
......................................................
Postcode ........................................		Emergency Contact Details
Home Tel ........................................		Name ..................................................................................
Work Tel ........................................		Home Tel ........................................................................
Mobile No .......................................		Mobile No ......................................................................
Email .............................................		Relationship ..................................................................

All information will be treated in the strictest confidence

Please answer all of the questions below. Indicate your answer by circling either Yes or No.

Does your work, leisure activity or any sport you play involve any of the following:

Sitting for long periods	Yes No	Driving	Yes No
Bending	Yes No	Standing	Yes No
Lifting or moving heavy weights	Yes No	Other repetitive Actions	Yes No

Will this be the first time that you have practised Pilates? Yes No
If NO, have you previously attended any of the following? (Please tick)
Studio At home (Book, video, DVD)	Body Control Pilates Matwork classes Other Pilates Matwork classes
Number of classes attended. (Please tick)... 0 - 5 ..... 5 - 10 ..... 10 - 20 ..... 20+

Are you, or could you be pregnant now?

Yes No

If YES, how many weeks into term are you? ...........

When is your due date?

Have you been pregnant in the last 6 months?

If YES, how was your baby delivered? ..... Normally.......... Caesarean

Yes No

Is your blood pressure normal?	Yes No
If NO, is your blood pressure	Hi . Lo
If your blood pressure is not normal, is it controlled with medication?	Yes No
When was your blood pressure last checked?

If you answer YES to any of the following questions, please give full relevant details for each condition in the space provided below.
1 Has your doctor ever said or otherwise indicated that you have any sort of heart trouble or defect?	Yes No
2 Do you feel pain in your chest when you undertake physical activity or experience shortness of breath?	Yes No
3 Do you suffer from: ........... Asthma.............. . Diabetes ............... Epilepsy (Please indicate Yes or No for each condition)
4 If YES, is the condition controlled with medication?	Yes No
5 Do you often get headaches?	Yes No
6 Do you lose your balance because of dizziness or do you ever lose consciousness, or feel faint or dizzy?	Yes No
7 Have you had major surgery in the last 10 years?	Yes No
8 Have you had minor surgery or sustained any injuries in the last two years?	Yes No
9 Have you ever been told that you have arthritic joints or any bone or joint problems that may be made worse by exercise?	Yes No
10 Do you suffer from: - ....................... Back pain .......................................................... Neck pain	Yes No
11 Do you have pain or restricted movement in any other joints (e.g. hip, knee, ankle, elbow, shoulder)?	Yes No
12. Have you been diagnosed as hyper-mobile (excessive joint mobility)?	Yes No
13. Are there any movements that cause you pain?	Yes No
14. Are you taking any drugs or medication that may affect your ability to exercise? Please give full relevant details here. Continue on a separate sheet if necessary.	Yes No

1

2

3

Please list here, any health problems you suffer, not already mentioned, that may affect your ability to exercise.

a

b

c

Have you been referred to Pilates by a specialist practitioner?

If YES, (Please tick)
GP........ Physiotherapist ..... Chiropractor .... Osteopath............ Other

Yes No

Do you hereby give permission for us to contact them?

If YES, please state in full, their name, address and contact number:

Practitioner's Name:........................................................................................

Practice Address:...........................................................................................

Practice Tel. No..............................................................................................

Yes No

What are your reasons for taking up Pilates?

1

2

3

What health or physical goals would you like to achieve over the next three months?

1

2

3

What long-term health or physical goals would you like to achieve over the next 12 months?

1

2

3

Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes (i.e. muscle soreness, joint pain, pulled muscles, minor injuries etc).

If you feel unwell (head cold, dizziness, sickness etc) it would be prudent not to attend class. This is primarily for your safety and well-being (your powers of concentration and performance levels may be below par and however slight, there is an increased risk of injury) and also in consideration for the comfort, well-being and health of other members in the class.

Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions.

It is not advisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise.

The sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of Pilates exercises, you should refer back to your medical practitioner.

The teacher can accept no liability for personal injury related to participation in a session if:

your doctor has, on health grounds, advised you against such exercise.
you fail to observe instructions on safety or technique.
such injury is caused by the negligence of another participant in the class/studio.

You are responsible for your own body, listen to it and respect it. Your ability to perform exercises may vary from session to session depending on your state of well-being, fitness, tiredness and/or stress levels. Exercise should be performed at a pace that feels comfortable for you. PAIN is the body's warning system and should NOT BE IGNORED.

Please inform your teacher immediately if you feel any discomfort during a session. Please also inform the teacher if you felt any discomfort after a previous session.

It is advisable to drink water during and after sessions to re-hydrate the body and to help flush out toxins that may have been released by your body as a result of the exercise programme. Increasing your water intake (6-8 large glasses per day) will also help to promote and improve your general health and well-being.

I understand that Body Control Pilates exercises involves hands-on (tactile) correction and I hereby consent for my teacher to work in this way.

I confirm that I have read and understood the above advice and that the information I have provided is correct.

Client Signature		Date ......./........../......
Teacher Signature		Date ......./........../......