Home - About Me - Gallery - Private Sessions - Classes - Studio Equipment Timetable/Charges - Testimonials - Contact Me - Enrolment Form - News - Links Personal Details Name Address Postcode Home Tel Work/Mobile Tel Email Sex Male Female   Date of Birth Occupation Sports, Hobbies Emergency Contact Details Name Home Tel Mobile All information provided will be treated in the strictest of confidence. PART 1 : Your current medical history YES NO Diabetes? If yes, please circle whether IDDM or NIDDM (Diet or medication controlled?) Are your glucose levels normalised? High or low blood pressure (BP)? If high, is your BP stabilised on medication or on Beta-blockers? Do you have medical clearance to exercise? Cardiac/heart problems? If yes, have you had an exercise stress test? If injured have you been cleared to exercise by your doctor? Epilepsy? If yes, have your seizures been stabilised on medication? Asthma or other breathing problems? If yes do you require regular medication during exercise? Have you been diagnosed with osteopenia/osteoporosis? Do you suffer from digestive complaints (ulcers, reflux, colitis etc?) Have you noticed any bowel or bladder dysfunction? If yes, please provide details: Have you noticed any recent unexplained weight loss? Have you been diagnosed with any form of cancer? If yes, where? Do you suffer from any neurological conditions or disease? Is there any other condition or disability not covered above that your therapist should be aware of in treating you as a Pilates client? Activities include stretching, bending, muscle strengthening and breathing exercises: PART 2 : Your symptom specific history Do you experience pain or discomfort? If yes, please note the painful areas with a 'P' on the body chart above and answer the following questions: Yes    No Where is the discomfort (e.g. outside of my left knee or under my right shoulder) __________________________________________________________ __________________________________________________________ Present since (if the result of an injury please summarize, e.g. motorcycle or skiing accident): __________________________________________________________ __________________________________________________________ Please place an x on the scale below to indicate the pain severity in relation to Question 1 A) What is your typical or average pain?     0(no pain) |___|___|___|___| 10(worst possible pain) B) What is your pain right now?     0(no pain) |___|___|___|___| 10(worst possible pain) Are you taking any pain relieving medication now? Yes    No Is it:   improving   unchanging   worsening   (please tick) Is it worse:   morning   afternoon   at night   (please tick) What makes your discomfort better (relieving factors): __________________________________________________________ __________________________________________________________ What makes your discomfort worse (aggravating factors): __________________________________________________________ __________________________________________________________ Please summaries any previous treatment and outcome: __________________________________________________________ __________________________________________________________ Please provide the name(s), occupation and telephone number of any relevant person currently treating you? __________________________________________________________ __________________________________________________________ Do you give me permission to contact them? Yes    No PART 3 : Your pregnancy history (where applicable) Are you or could you be pregnant now? Yes    No If yes, when is your due date? __________________________________________________________ __________________________________________________________ Have you had any pregnancies? If so, how many? Please list delivery years: __________________________________________________________ __________________________________________________________ Delivery type/s:   natural   caesarean   assisted   (please tick) Do you know how you were delivered?   natural   caesarean   assisted   (please tick) Additional pregnancy information: __________________________________________________________ __________________________________________________________ PART 4 : Your past medical history Yes     No           Have you been involved in a major accident? (Including motor vehicle accidents?) If yes, please specify:           Have you had any surgery? If yes, please specify:           Have you had any bone or stress fracture? If yes, do you currently have any metal plates/pins or screws in place?           Have you had any foot or ankle problems/injuries? If yes, please specify:           Have you had any knee or hip problems/injuries? If yes, please specify:           Have you had any shoulder/elbow or wrist problems/injuries? If yes, please specify:           Have you had any other muscle/ligament or tendon problems/injuries? If yes, please specify:           Have you had any neck problems/injuries (e.g. whiplash)? If yes, please indicate the date:           Have you had any low back problems/injuries? If so, please indicate the date the date/s of your first and any subsequent episodes:           Are you currently off work due to pain or disability? If yes, how long have you been off?           Have you been diagnosed as hypermobile (excessive joint mobility)? Please list any other fitness or sports training you are doing, include the frequency: __________________________________________________________ __________________________________________________________           Do you feel your work contributes to your symptoms?           Have you had any recent investigations (X-ray/MRI-scans or blood tests)?           Do you have any relevant reports or referrals to provide us with in relation to your treatment?           Are you taking any medications not already mentioned in this questionnaire?           Is there a history of ill health (heart disease, cancer, diabetes) in your family? (Including parents, grandparents, siblings) Please print any additional comments here: __________________________________________________________ __________________________________________________________ What are your reasons for taking up pilates? __________________________________________________________ __________________________________________________________ What health or physical goals would you like to achieve in the next three months? __________________________________________________________ __________________________________________________________ What longer term health or physical goals would you like to achieve in the next 12 months? __________________________________________________________ __________________________________________________________ PART 5 : Important Information(To be done by hand) Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes. It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with you teacher. It is also wise to wait six weeks after birth before resuming exercise. Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions. These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of these 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 th negligence of another participant in the class/studio. Exercise should be performed at a pace which feels comfortable for you. PAIN is the body's warning system and should NOT BE IGNORED. Please inform your teacher immediatley if you any discomfort during a session. Please also inform the teacher if you felt any discomfort after a previous session. I understand that these exercises involve hands-on correction and I hereby consent for my teachers to work in this way. Client ________________________________________ Date ____________________ Teacher ________________________________________ Date ____________________ Return to: Carina Bayley Hollyhocks Place Guildford Road Cranleigh GU6 8PA [Back to Top]
Posture Perfect Pilates, Hollyhocks Place, Guildford Road, Cranleigh, Surrey, GU6 8PA Tel: 01483 273374 / 07712 187355       Mobile: 07712 187355       Email: Carina@CBayley.com