Contact – Amy Cooke Movement

Name

First

Last

Address :

Phone Number

Email

Postal Code

Daytime / Other Telephone Number

Date of Birth

Emergency Contact Number

Which class or session do you wish to attend?

PILATES AIMS - 1) Have you done Pilates before?

2) What are your main aims which you are hoping to achieve through Pilates? To Improve

3) Have you been recommend Pilates by a specialist?

If yes, by who?

LIFESTYLE - What is your occupation?

If yes please give brief explanation

Does your occupation involve any repetitive movements or prolonged postures?

What other hobbies, sports or exercise are you involved in?

HEALTH QUESTIONAIRE - 1) Do you have any of the following conditions?

If you have answered yes to any of the above please give further details.

2) Women only : Are you pregnant?

if yes, how many weeks pregnant are you?

If yes, have you had any complications in your pregnancy? Please give details

3) Have you ever had an episode of low back pain?

If yes, how many previous episodes of low back pain have you had?

Pilates Participation Informed Consent. The Pilates programme will begin at a low level and will be advanced in stages depending on your fitness level. We may stop an exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort. There exists a possibility of certain dangers when exercising. They include abnormal blood pressure, feinting, irregular, fast or slow heart rhythm, and in rare instances heart attack, stroke or death. Whilst every care will be taken it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during exercising. I understand that there may be an element of hands-on teaching / correction of the exercises during the Pilates class and that I can request a hands-off approach if I wish. I understand it is my responsibility not to work beyond my usual level of difficulty and to make my own adaptations as needed. I confirm that I have checked with my Doctor about any of the health problems detailed above, and that they are happy for me to participate in Pilates. I will inform my Pilates teacher of any changes to my health which may affect my ability to exercise, as detailed in the health questionnaire above. This information is protected by the Data Protection Act 1984.

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