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Registration Form
Registration Form
Name
Name
First
First
Last
Last
Address :
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Phone Number
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Email
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Postal Code
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Daytime / Other Telephone Number
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Date of Birth
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Emergency Contact Number
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Which class or session do you wish to attend?
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Group Class @Ownzone in Stroud
One-to-One
Duet
PILATES AIMS - 1) Have you done Pilates before?
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Yes
No
2) What are your main aims which you are hoping to achieve through Pilates? To Improve
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Core Stability
Flexibility
Posture
Toning
Strength
Sports Performance
Stress Management
Relaxation
Low Back Pain
Other
3) Have you been recommend Pilates by a specialist?
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Yes
No
If yes, by who?
Physiotherapist
Chiropractor
Osteopath
GP
Consultant
Other
LIFESTYLE - What is your occupation?
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If yes please give brief explanation
Does your occupation involve any repetitive movements or prolonged postures?
Yes
No
What other hobbies, sports or exercise are you involved in?
HEALTH QUESTIONAIRE - 1) Do you have any of the following conditions?
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1) Low back Pain
2) Pelvic Pain
3) Any other Spinal Condition?
4) Any Musculoskeletal condition - eg Osteoporosis, arthritis, hypermobility
5) Heart Problems
6) High or low blood pressure
7) Epilepsy
8) Diabetes
9) Stroke
10) Cancer
11) Recent injury or surgery
None
If you have answered yes to any of the above please give further details.
2) Women only : Are you pregnant?
Yes
No
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?
Yes
No
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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