Full Name(Mr/Mrs/Miss/Ms)



    Phone (Home)

    Phone (Work)

    Phone (Mobile)

    Email Address

    Date of Birth


    Sports/Hobbies/Other form of exercise


    Does your work or sport/hobbies involve any of the following?- Please tick

    Any other repetitive action, please describe

    Has your Doctor ever mentioned that you have any kind of heart problem, chest pain or defect?

    Are you asthmatic?

    Do you suffer from diabetes?

    Your blood pressure

    Have you ever been told that you have arthritic joints or any bone or joint problem that may be made worse by exercise?

    Have you had any operations or injuries in the last year?

    Are you pregnant or have you had a baby in the last six months?

    Do you know any other reason, not yet mentioned, that should stop you from performing physical exercise?

    Have you been referred?

    Any past history of injuries?

    Do you suffer from backache?

    Have you ever been given any remedial exercise?

    Are there any movements that cause you pain?(Example raising your arms, bending forward or to the side etc.)

    If you wish to strengthen a particular area please indicate

    Any other comments (optional)

    Important Notice

    Pilates exercise are very safe but as with all forms of exercise, it is recommended that you consult your doctor if you suffer from any health problems or special conditions or are in any doubt as to its suitability.
    If you are undergoing medical treatment or are taking drugs – again you will need to consult your medical practitioners first.

    Pilates should not be considered a replacement for professional medical treatment.

    In respect of pregnancy it is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with the instructor. It is advised to wait six week, after giving birth, before resuming exercise.

    The instructor can accept no liability related to participation in a class if:

    1. Your doctor has advised you against such exercise

    2. You fail to observe instruction on safety or technique

    3. Such injury is caused by negligence of another participant in the class