Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Mobile
Country
(###)
###
####
Email
*
Occupation
Sports, Hobbies
Gender
Female
Male
Other
Rather not say
Does your work or the sports you do involve any of the following?
Please specify if there are other repetitive actions.
How many times a week do you usually exercise
None
1-2 times
3-4 times
5-6 times
7+ times
Have you previously practiced mat based Pilates?
If yes, please specify roughly how many sessions.
1-10 sessions
10-20 sessions
20+ sessions
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness/feel faint?
Is your doctor currently prescribing medication for your blood pressure or a heart condition?
Are you currently pregnant?
If yes, congratulations! Our programs are currently not suitable for you. Please indicate if you would like us to contact you in the future to invite you to work with us.
If yes, select a date to be contacted
Please give at leasy 6 weeks after birth before resuming exercising.
MM
DD
YYYY
If you had a baby in the last 6 months, how were they delivered and when?
Have you had surgery in the last 10 years?
e.g. joint replacement, heart surgery, etc
If yes, please provide details, please include any advice given on movements to be avoided currently or that are limited as a result.
Have you been advised not to exercises as a result?
Please provide more details, if any.
Do you have a bone or joint problem?
e.g. arthritis, osteoporosis, osteopenia, etc
Do you suffer from neck or back pain?
If yes, what movements tend to aggravate it?
e.g. bending to put on shoe, looking upwards, etc
Do you have pain or restricted movement in any other joints?
If yes, please specify.
e.g. hip, knee, ankle, shoulder, etc
Have you been diagnosed as hypermobile?
Do you know of any other reason why you should not do physical activity? Please specify.
Are you taking any drugs or medication which may affect your ability to exercise?
If yes, please specify.
Have you ever been recommended to take up Pilates by a specialist?
e.g. Physiotherapist, other health care practitioner, etc
If yes, please provide some details.
Please list any health problems you suffer from, not already mentioned, that may affect your ability to exercise that has occurred within the last 3 months.
e.g. heel pain, muscle tear, etc
What are your aims for taking up Pilates? Please choose a max of 3.
What longer-term health or physical goals would you like to achieve over the next twelve months?
Declaration
*
Please advise us before commencing any session, if for any reason, your health or your ability to exercise changes.
Our programs are not designed for pre-natal and you should not engage in our programs until after you have given birth. It is also wise to wait six weeks after the birth before resuming exercise and you should receive the 'all clear' from your midwife/medical practitioner.
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 your 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 practitioner 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 contact us on the website via the “Contact us” form if you feel any discomfort after a previous session.
Liability Waiver
*
In agreeing to participate in any online session/class/workshop/programs with Anchored Pilates or in associated online classes I acknowledge and accept that my participation is completely at my own risk.
As a participant, I hereby waive, release, and forever discharge Anchored Pilates and associated teachers from any and all responsibilities or liability from injuries or damages resulting from my participation in the above-mentioned activities.
I confirm that I am voluntarily participating in Anchored Pilates online session/class/workshop/programs.
I agree to disclose any physical condition, disabilities, ailments which may affect my ability to participate in any physical exercise. I certify that I am in good health and sufficient physical condition to participate in this online Pilates class.
I understand and am aware that exercise is a potentially hazardous activity. I also understand that fitness activities involve risk of injury and even death, and I am voluntarily participating in these activities and using equipment with knowledge of the dangers involved. I expressly assume and accept all risks.
Terms and conditions:
We recommend you consult with a physician before starting this or any
exercise program. If you experience any pain or discomfort during the course of the
session/class/workshop/programs stop exercising immediately and seek medical attention.
