CLIENT ENROLMENT FORM

ALL INFORMATION WILL BE TREATED IN THE STRICTEST OF CONFIDENCE

You will need to complete the following Client Enrolment Form prior to your first session with us at Pilates Lodge.

We kindly ask that all clients complete an enrolment form before their introductory session.
If you experience any issues completing this form, we can provide a hard copy for you to complete upon arrival at your first session.
This enrolment form is a copy of the Body Control Pilates CER18 Client Enrolment Form 2018.
If you are pregnant or booking your first postnatal pilates session, we have a different enrolment form for you to complete. Please email us on info@pilateslodge.com and we will send you the correct version.

– Step 1 of 5

Part 1 – Personal Details

Name *

First

Last

Your Address *

Contact Telephone Number *

Email *

Sex

Male
Female
Rather Not Say

Date Of Birth *

Occupation

Sports & Hobbies

Part 2 – Emergency Contact Details

Emergency Contact Name *

First

Last

Emergency Contact Number *

Emergency Contact Email Address *

Part 3 – Your Background & Health

1) Does Your Work / Sport Involve Any Of The Following?

Sitting For Long Periods
Driving
Bending
Standing
Lifting Heavy Weights
Any Other Repetitive Action

2) Will This Be The First Time You Have Practised Pilates? *

If NO, Have You Previously Attended

Studio
Body Control Matwork Classes
Other Pilates Matwork
At Home (Book,DVD)

Number Of Classes Previously Attended *

0-5
5-10
10-20
20+

3) Has Your Doctor Ever Said You Have Any Sort Of Heart Trouble Or Defect? *

4) Do You Feel Pain In Your Chest When You Undertake Physical Activity? *

5) Are You, Or Could You Be Pregnant Now?

If Yes, When Is Your Due Date?

6) Have You Been Pregnant In The Last 6 Months?

7) If You Have Had A Baby, How Was It Delivered?

Vaginal
Caesarean
Vaginal With Intervention (eg Forceps)

8) Do You Often Get Headaches? *

9) Do You Lose Your Balance Because Of Dizziness? Or Do You Ever Lose Consciousness, Feel Faint Or Dizzy? *

10) Do You Have High Blood Pressure? *

If YES, Is This Regulated By Medication? Please Give Details

11) Is Your Blood Pressure *

Normal
Low

12) Have You Had Major Surgery In The Last 10 Years? *

13) Have You Had Minor Surgery In The Last 2 Years? *

14) Do You Suffer From Asthma, Diabetes Or Epilepsy? *

15) Have You Ever Been Told You Have Arthritic Joints, Osteoporosis, Osteopenia Or Any Bone Or Joint Problem That May Be Made Worse By Exercising? *

16) Do You Suffer From Back Or Neck Pain? *

17) Do You Have Pain Or Restricted Movement In Any Other Joints (eg Hip, Ankle, Knee, Shoulder)? *

18) Have You Ever Been Diagnosed As Hypermobile (Excessive Joint Mobility)? *

19) If You Have Answered YES To Any Of Questions 14-18, Do You Have Medical Permission To Exercise?

20) Are There Any Movements That Cause You Pain? *

21) Are You Taking Any Drugs Or Medication That May Affect Your Ability To Exercise? *

22) Have You Ever Been Recommended To Take Up Pilates By A Medical Practitioner? *

If YES, Was It By Your

GP
Physiotherapist
Chiropractor
Osteopath
Other

23) Do You Hereby Give Us Your Permission To Contact Them?

If YES, Please Provide Their Name & Contact Number

Please list any health problems you suffer, not already mentioned, that may affect your ability to exercise. If you have answered YES to any of questions 3-21 above, we advise you consult with your medical practitioner before you start Pilates Classes. Please give further relevant details below, in confidence, to any questions you ticked YES. Are there any factors your teacher should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?

Part 4 – Your Aims

What Are Your Reasons For Taking Up Pilates? *

What Health Or Physical Goals Would You Like To Achieve Over The Next Three Months? *

What Longer-Term Health Or Physical Goals Would You Like To Achieve Over The Next 12 Months? *

Part 5 – Important Information

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 your teacher. It is also wise to wait six weeks after the 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 the 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 the 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 immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session.

I understand that Body Control Pilates exercises involve hands-on correction and I hereby consent for my teachers to work in this way.

I confirm that I have read and understood the above advice and that the information I have given is correct.

I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information:

will be used in confidence and stored securely
will not, in any circumstances, be shared with a third party without my written consent, unless that party is another (Body Control) Pilates teacher who will teach me.
may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfil

I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time.

Please Type Your Full Name *

Todays Date *

LINKS

TERMS

Terms & Conditions

CONTACT

info@pilateslodge.com

07460 493488

Springfields, EN10 7LX

Facebook Instagram

Pilates Lodge 2021 – Designed & Built By Firston Media