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Pre-Exercise Readiness Questionnaire

All information will be treated with the strictest of confidence. It is important that you disclose as much detail as possible so that I can determine readiness for exercise before commencing a class or personal training. 

Date of birth
Exercise Experience
None
Beginner
Moderate
Gym/ClassSetting

Personal Health History

Please read the following carefully, and delete what is not applicable. If you do not understand questions or are unclear or anything on this form, please ask your instructor before you sign it. Delete what is not applicable.

Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?
No
Yes
Do you experience chest pain brought on by physical activity or exertion?
No
Yes
Have you ever had a stroke, heart murmur, and or heart palpitation?
No
Yes
Do you have epilepsy?
No
Yes
Experienced loss of consciousness or fallen over as a result or dizziness?
No
Yes
Ever been recommended medication for your blood pressure or a heart condition?
No
Yes
Do you suffer from any condition that affects your joints which may be aggravated by exercise? E.g hypermobility, arthritis
No
Yes
Are you taking any prescribed medication?
No
Yes
Do you suffer from Asthma or Diabetes?
No
Yes
Are you pregnant or have you been pregnant in the last 9 months?
No
Yes
Are you pregnant or have you been pregnant in the last 9 months?
No
Yes

Have you experienced in past or present any of the following:

Miscarriage, incompetent cervix, pre eclampsia, chest pains, seizures, heart disease, pelvic or abdominal cramps, vaginal bleeding, multiple gestation, shortness of breath, blood disorder, hypoglycaemia, gestational diabetes
No
Yes
Have you suffered with pelvic girdle pain e.g. pubic symphysis dysfunction/sacroiliac joint pain?
No
Yes
Are there any movements or positions which cause you pain?
No
Yes
Do you have any particular concerns or worries about pelvic floor health? i.e. experience urine leakage, lack of sensation, feeling of heaviness or bulging, or any discomfort?
No
Yes
Are you breastfeeding or did you breastfeed in the last 9 months?
No
Yes

TERMS AND CONDITIONS FOR PERSONAL TRAINING: 


Pre-payment is required. Invoice’s will be sent at the beginning of the month, once paid your sessions will be blocked out in the diary. 


Less than 24 hours notice when cancelling a session will incur a fee. 


More than 3 consecutive missed sessions could risk your regular slot being offered to someone else.


Block booking policy is 1 or 2 sessions per week, if you need to cancel a session please consider that I will try my best to fit in you but there may not always be space to rearrange it, therefore the session could be lost. All block bookings have an expiry date which will be stated when booked. 


Please let me know if you are going to be late, more than 15 minutes late the session will have to be cancelled. 

I hereby state that I have read, understood and answered honestly the questions above and that any statements made by me in answering this Pre-Activity Questionnaire are true and accurate. I also state that I wish to participate in agreed activities (boxing, Pilates, Pilates reformer, resistance training). I realize that my participation in these activities involves a risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise given my knowledge of my health and will comply with any medical advice I have received.

Please advise your instructor before commencing any session if for any reason your health or ability to exercise changes. If in doubt of exercises please refer back to your preferred medical practitioner. The instructor can accept no liability for personal injury related to participation in a session, if: 

  • Doctor has not given medical clearance to exercise or continue to exercise

  • You fail to observe instructions on safety and technique

  • Such injury is caused by the negligence of another participant in the class/studio space

I understand as a Pilates teacher my instructor will give hands on correction and I hereby consent for my instructor to work in this way.

Electronically signed by

Date

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