Please complete this form to help us understand your current health status and medical history.
You are responsible for correctly using our facilities and agree to observe the conditions in the Health Commitment Statement which you agreed to when registering for an account on the website.
Exercise carries its own risks. Your health is your responsibility and you accept that Pilates Near staff are not medically trained. We ask that you do not exercise beyond your own abilities or carry out activities which you know or believe to be unsuitable for you. You agree:
- You accept that our staff are not medically trained.
- If you know or are concerned that you have a medical condition, injury or pregnancy that may impact your ability to exercise, you will seek relevant medical advice and follow that advice before you use our equipment, facilities or attend classes.
- You will let us know immediately if you feel unwell during class or when using our equipment or facilities.
- If you have a disability, you will let us know and follow any reasonable instructions to allow you to exercise safely.
We reserve the right to ask you to leave a class or refuse access to a class if we reasonably consider that your conduct is damaging to our reputation, the experience of other customers, in breach of these Terms and Conditions, or if it would otherwise be in the interests of our other customers.
Name:
Date of Birth:
Date Joined:
Mobile Number and/or Landline:
Email:
Emergency Contact Name and phone number:
- Has your Doctor ever indicated that you have a heart condition? Have you ever had a heart attack? Have you ever experienced chest pains during physical exertion? Y N
- Do you suffer from high blood pressure or have high cholesterol? Y N
- Have you experienced any dizziness, felt faint or fainted? Y N
- Do you have any bone, joint or other muscular problems? Y N
- Are you pregnant or have been within the last six months? Y N
- Are you diabetic? Y N
- Are you asthmatic? Y N
- Do you suffer from arthritis? Y N
- Do you suffer from epilepsy? Y N
- Are you currently taking any prescribed or unprescribed medications, or recreational drugs? Y N
- Are you currently under a doctor’s care for any condition? (If yes, please specify) Y N
I confirm that the information provided above is accurate to the best of my knowledge.
Signature:
Date:
Privacy Statement: The information provided in this form will be kept confidential and used only for the purpose of providing you with appropriate care. It will be stored securely in accordance with data protection regulations.