Health Waiver-OLD PAGE

Health Waiver

Please complete the following information so I can get to know you better, understand your needs and make the most of your Pilates experience!

First Name

Last Name

Date of Birth

Phone Number

Next of Kin - Name and Phone Number in case of an emergency:

Please select any of the following that apply to you:

Lower Back Pain

Mid Back/Thoracic/Rib issues

Shoulder Pain

Neck Pain

Hip Pain

Any other joint (knee, wrist, hip, etc) pain or injury

Spinal condition such as Osteoporosis/Osteopenia, Arthritis, etc

Chronic or Long Term condition

High or Low Blood Pressure (not controlled)

If you ticked any of the above, please add further details here. Or add any other health issue or injury not listed:

Have you ever had surgery? If yes, please give details: 1) what you had done; 2) when (month/year) 3) left or right side if applicable 4) if you have made a full recovery or had clearance to exercise?

Are there any movements you struggle with, or that cause pain?

Occupation:

List any regular sports or hobbies, & any frequent/repetitive movements you perform, if any:

Have you ever done Pilates before?

Yes

If YES, how long for? And how long ago?

What is your reason to start Pilates? You might like to list your goals here. (eg: Improve at your chosen sport or a daily movement; Reduce pain; Improve strength; Increase flexibility; Have fun, Reduce stress, etc)

I agree to exercise within my level of capability. I understand all exercise carries some degree of risk and agree that it is my responsibility to follow instructions and make decisions to work within my own limitations.

I agree to the terms & conditions. Private Pilates: Cancellations within 24 hours of my agreed appointment time will result in the full cost of a session. Group Block Bookings: There are no refunds on block bookings for classes missed.

Full T&C's and Cancellation Policy can be read here:

https://www.thepilatesphysio.com.au/cancellationtandcs

I want to subscribe to the mailing list.

Your Signature