Consultation & Enrolment Form

Please complete this form after confirming your place on a course.

Personal Details

Where did you find out about us?

Have you ever had any of the following treatments?

Medical Information

1) Have you ever had any of the following?

If you have indicated any of the above, please give further details here:

2) Any chance you could be pregnant?

Have you been pregnant in the last 6 months?

If yes, please give further details:

3) If you have had a baby, how was it delivered?

4) At what age did you go through the menopause?

5) Do you wear orthotics / shoe inserts?

6) Please list any current medication:

7) Have you ever had any surgery?

If yes, please give further details including dates (approx.)
If hysterectomy please give details as to what type, i.e. exactly what was and wasn't removed.

Date:

Type of Surgery:

Further Details:

8) Have you had any accidents/injuries in the past?

If yes, please give further details:

9) Are you currently suffering from pain or injury?

If yes, please give further details:

Lifestyle

What type of exercise do you undertake?

Pilates Clients Only

Have you practiced pilates before?

If yes, please check boxes as applicable:

Has Pilates been recommended by a practitioner?

If yes, please check boxes as applicable:

Are there any movements that cause you pain / restriction?

If yes, please give further details:

What are your reasons for taking up pilates?

Medical Advice

If you have answered yes to Questions 1-9 above, we advise you consult with your medical practitioner before you start Pilates Classes. The therapist/ teacher can accept no liability for personal injury if your doctor has, on health grounds advised you against such exercise, or if you fail to observe instructions on safety or technique, or if such injury is caused by the negligence of another participant in the class. Exercise should be performed at a pace which feels comfortable for you, please inform your teacher if you feel any discomfort during a session or after a previous session.

Declaration

I declare that all information given on this form is true and correct to the best of my knowledge. I understand and consent to undergo Massage treatments and/or Pilates, based on the explanation I have received about this, and the medical information I have provided above. If I have answered yes to questions 1 or 9 above, I confirm that I have had medical permission to exercise. I understand that it is my responsibility to inform the therapist/teacher of any changes to the information given. I understand that Body Control Pilates and STOTT Pilates exercises involve hands-on correction and I hereby consent for my teachers to work in this way.

I also confirm that my teacher/therapist may use the contents of this form and any other information I may later provide, for teaching or massage therapy purposes, and that this information will be used in confidence and stored securely and will not in any circumstances be shared with a third party without my written consent, other than employees of Upminster Sports Massage & Pilates. This form may be retained by the teacher/therapist for a period of time such as complies with professional, legal and insurance requirements that they must fulfil. I confirm agreement for Upminster Sports Massage & Pilates to contact me with information on Pilates classes and other Pilates or Sports Massage related activities, and understand that I have the right to withdraw this 'consent to be contacted' at any time.

Please enter your full name and today's date into the boxes below.