Client Enrolment Form

Please complete our digital Client Enrolment form below, or, download a PDF copy of our paper enrolment form by clicking here.

Name(Required)

First Last

Address(Required)

Postcode(Required)

Daytime Telephone(Required)

Evening Telephone(Required)

Mobile Telephone(Required)

Email Address(Required)

Date of Birth(Required)

Occupation(Required)

Sports/Hobbies(Required)

Previous Pilates Experience (if any)

Emergency Contact Details

Name(Required)

Telephone(Required)

Mobile Telephone(Required)

Work

Please tick

Does your work/sport/daily activity involve any of the following?

Sitting for long periods

Driving

Bending

Standing for long periods

Lifting heavy weights

Repetitive actions

Working at a computer

Actions which cause strain

Health

1. Do you have any sort of heart condition or defect?(Required)

Yes

2. Do you feel pain in your chest when you do physical activity?(Required)

Yes

3. Do you ever lose your balance because of dizziness or ever lose consciousness?(Required)

Yes

4. Do you have arthritic joints osteoporosis or any bone or joint problems?(Required)

Yes

5. Do you suffer from back, neck or shoulder problems?(Required)

Yes

6. Do you have pain or restricted movement in any joints (e.g. hip, knee, ankle, elbow)?(Required)

Yes

7. Have you been diagnosed as hypermobile (excessive joint mobility)?(Required)

Yes

8. Have you had any injuries in the last year?(Required)

Yes

9. Have you had surgery within the last five years?(Required)

Yes

10. Are you taking any medication that could affect your ability to exercise?(Required)

Yes

11. Is your blood pressure:(Required)

Normal

High

Low

12. Do you have:

Asthma/COPD

Epilepsy

Allergies

13. Are you pregnant or have you had a baby in the last year?(Required)

Yes

14. Is there any other reason why you should restrict physical exercise?(Required)

Yes

15. Have you been referred by your GP or a specialist practitioner • • (e.g. GP, physio, chiropractor osteopath)? If so, and you give permission for me to contact them, please give their name and contact details below.(Required)

Yes

Further Details(Required)

If you answered YES to any of the above it is advisable to consult with your doctor before starting Pilates classes. Please give below any further details, in confidence, to any questions answered YES or if there is any other relevant information that may affect your ability to exercise.

Pilates classes are generally considered safe and effective. However, they are not intended to replace medical advice or treatment and if you have any doubt about the suitability of Pilates exercises for you, then seek advice from your medical or specialist practitioner. Exercise should be performed at a pace which feels comfortable for you. Please inform your instructor immediately if you experience pain or discomfort during a session or after a previous session. If your health changes so that subsequently you answer YES to any of the above, please inform your instructor. I understand that the information provided here, will be kept safely and securely in line with the Privacy Notice of Beryl Feely, a copy of which has been provided to me/details of which have been explained to me.

If you are unwell or have any of the symptoms of Covid19 please stay at home and keep yourself and others safe.

I agree to be contacted an sent information by:(Required)

Phone

Text/SMS

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

Signed(Required)

Your data will be used in accordance with our Privacy Notice.

Name

This field is for validation purposes and should be left unchanged.