Enrolment Form - Healthy Back - My Local Pilates - Classes and courses in Hackney, Homerton, Hackney Wick, Clapton

Name *

First

Last

Address *

Contact Tel *

Mobile *

Email *

Sex *

Male Female

Date of Birth (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:

Part 2: Pregnancy

Part 3: Background Information

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.

Client Enrolment Form
Healthy Back

Personal Details

Emergency Contact

Your GP

PART 1: General Medical Information

Part 2: Pregnancy

Part 3: Background Information

Part 4: About Your Back

Part 5: Important Information

Client Enrolment FormHealthy Back

Personal Details

Emergency Contact

Your GP

PART 1: General Medical Information

Part 2: Pregnancy

Part 3: Background Information

Part 4: About Your Back

Part 5: Important Information

Client Enrolment Form
Healthy Back