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Locations
Victoria Park Harriers, Homerton
Chats Palace, Lower Clapton
HBC Community Centre, Homerton
Pilates in the Park
Classes
Group Classes
Initial Assessment
Private Classes
Corporate Classes
Teachers
Sam White - Founder and Principal Teacher
Danai Pappa
Sophie Balaam
Emma Illingworth
Annabelle Ledbrooke
Rosamond Martin
Han Cherry
Ellen Leishman
Testimonials - Client Feedback
About Pilates
Pilates Background
Back Pain Pilates
More About Low Back Pain
FAQ's
Contact
Home
Timetable & Booking
Timetable
Class Prices
Online Booking
How to Join an Online Class
Important Info
Health Questionnaire
Term Dates
Terms and Conditions
Privacy Policy
Latest Newsletters
Locations
Victoria Park Harriers, Homerton
Chats Palace, Lower Clapton
HBC Community Centre, Homerton
Pilates in the Park
Classes
Group Classes
Initial Assessment
Private Classes
Corporate Classes
Teachers
Sam White - Founder and Principal Teacher
Danai Pappa
Sophie Balaam
Emma Illingworth
Annabelle Ledbrooke
Rosamond Martin
Han Cherry
Ellen Leishman
Testimonials - Client Feedback
About Pilates
Pilates Background
Back Pain Pilates
More About Low Back Pain
FAQ's
Contact
Client Enrolment Form
Healthy Back
All information will be treated in the strictest of confidence
Personal Details
*
Indicates required field
Name
*
First
Last
Address
*
Contact Tel
*
Mobile
*
Email
*
Sex
*
Male
Female
Date of Birth (dd/mm/yy)
*
dd/mm/yy
Occupation
*
Current recreational activities
*
Previous recreational activities
*
How did you hear about the Back4Good(R) 'Healthy Back' classes?
*
Emergency Contact
Name
*
Relationship
*
Mobile
*
Your GP
Have you been referred by your GP or by any other medical practitioner?
*
Yes
No
Do you give me permission to contact your GP about the issues directly relating to your participation in the Back4Good(R) 'Healthy Back' class?
*
Yes
No
If YES, please provide any relevant information here and provide their contact details in the box below:
*
GP Name
*
Surgery Address
*
PART 1: General Medical Information
Do you suffer from any of the following? If yes, please give details where requested:
1. Diabetes?
*
Yes
No
If YES, please indicate whether IDDM or NIDDM (diet or medication controlled). Are your glucose levels normalised?
*
2. High or low blood pressure?
*
High
Low
Normal
If HIGH, is it stabilised with medication and do you have medical clearance to exercise?
*
3. Cardiac / heart problems or angina?
*
Yes
No
If YES, do you have medical clearance to exercise?
*
4. Do you suffer from any vascular conditions or diseases (DVT, aneurysm etc.)?
*
Yes
No
If YES, do you have medical clearance to exercise?
*
5. Epilepsy
*
Yes
No
If YES, have your seizures been stabilised with medication?
*
6. Asthma or breathing problems
*
Yes
No
If YES, do you require medication during exercise?
*
7. Do you suffer from digestive complaints? (ulcers, reflux, colitis etc.)?
*
Yes
No
If YES, please give details:
*
8. Have you noticed any bowel or bladder dysfunction?
*
Yes
No
If YES, please give details:
*
9. Have you noticed any recent unexplained weight loss?
*
Yes
No
If YES, please give details:
*
10. Have you ever ben diagnosed with any form of cancer?
*
Yes
No
If YES, please give details:
*
11. Do you suffer from any neurological conditions or diseases?
*
Yes
No
If YES, please give details:
*
Part 2: Pregnancy
13. Are you, or could you be, pregnant now?
*
Yes
No
If YES, please give details:
*
14. Have you had any previous pregnancies?
*
Yes
No
If YES, please give details:
*
14.1. Please check the delivery types you have had:
*
Natural
Caesarean
Assisted
Forceps
Episiotomy
Part 3: Background Information
15. Do you suffer from any inflammatory conditions or diseases (such as rheumatoid arthritis, polymyalgia rheumatic etc.)?
*
Yes
No
If YES, please give details:
*
16. Do you suffer from osteoporosis or osteopenia?
*
Yes
No
If YES, please give details, including your T-score if you know it:
*
17. Have you ever been involved in a major accident (including motor vehicle accidents)?
*
Yes
No
If YES, please give details:
*
18. Have you had any surgery?
*
Yes
No
If YES, please give details:
*
19. Have you suffered and broken or fractured bones (including stress fractures)?
*
Yes
No
If YES, please give details:
*
20. Have you had or do you have any joint or soft tissue problems/injuries (muscle, tendon or ligament)?
*
Yes
No
If YES, please give details:
*
21. Have you been diagnosed as hypermobile (excessive joint mobility)?
*
Yes
No
If YES, please give details:
*
Part 4: About Your Back
If you have, or have had, any lower back pain please provide details here, including the approximate date(s) of your first and any subsequent episodes:
*
Have you ever had any formal diagnosis related to any incidents of lower back pain? If yes, please give details:
*
Is there any other information not asked for above that you feel may be relevant to you attending Back4Good(R) 'Healthy Back' classes?
*
What are your goals and expectations on starting your 'Healthy Back' sessions?
*
Part 5: Important Information
Please advise us before commencing any session if, for any reason, your health or ability to exercise changes.
It is inadvisable to do any exercise 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 warming system and should NOT BE IGNORED. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform the 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 teachers to work in this way.
Electronic Signature
*
I confirm that I have read and understood the above advice and that the information I have given is correct
Date of agreement
*
dd/mm/yy
Submit
Home
Timetable & Booking
Timetable
Class Prices
Online Booking
How to Join an Online Class
Important Info
Health Questionnaire
Term Dates
Terms and Conditions
Privacy Policy
Latest Newsletters
Locations
Victoria Park Harriers, Homerton
Chats Palace, Lower Clapton
HBC Community Centre, Homerton
Pilates in the Park
Classes
Group Classes
Initial Assessment
Private Classes
Corporate Classes
Teachers
Sam White - Founder and Principal Teacher
Danai Pappa
Sophie Balaam
Emma Illingworth
Annabelle Ledbrooke
Rosamond Martin
Han Cherry
Ellen Leishman
Testimonials - Client Feedback
About Pilates
Pilates Background
Back Pain Pilates
More About Low Back Pain
FAQ's
Contact
