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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
Caroline Kinch
Emma Illingworth
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
Caroline Kinch
Emma Illingworth
Testimonials - Client Feedback
About Pilates
Pilates Background
Back Pain Pilates
More About Low Back Pain
FAQ's
Contact
Client Enrolment Form
Standard Matwork
All information will be treated in the strictest of confidence
All questions with a red asterix (
*
) must be completed. This form is an electronic copy of the standard paper Body Control enrolment form.
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
*
Sports, Hobbies
*
Enter details of any sports or hobbies you actively partake in. Please also list any sports or hobbies that you have previously practised if relevant.
Emergency Contact
Name
*
Name of the person to contact in case of emergency.
Relationship
*
Mobile
*
PART 1: Your Background and Your Health
1. Does your work/sport involve any of the following?
*
Sitting for long periods
Bending
Lifting heavy weights
Driving
Standing
Any other repetitive action
2. Will this be the first time you have practiced Pilates?
*
Yes
No
2.1. If NO, have you previously attended:
*
Studio
Body Control Pilates Matwork classes
Other Pilates matwork
At home (book, DVD)
2.2. Number of classes attended:
*
0-5
5-10
10-20
20+
3. Has your doctor ever said that you have any sort of heart trouble or defect?
*
Yes
No
4. Do you feel any pain in your chest when you undertake physical activity?
*
Yes
No
5. Are you, or could you be, pregnant now?
*
Yes
No
If YES, when is your due date?
*
dd/mm/yy
6. Have you been pregnant in the last six months?
*
Yes
No
7. If you have had a baby, how was it delivered?
*
normally
caesarean
normally with intervention (e.g. forceps)
8. Do you often get headaches?
*
Yes
No
9. Do you ever lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy?
*
Yes
No
10. Do you have HIGH blood pressure?
*
Yes
No
11. Do you have LOW blood pressure?
*
Yes
No
12. Have you had major surgery in the last 10 years?
*
Yes
No
13. Have you had minor surgery in the last two years?
*
Yes
No
14. Do you suffer from asthma, diabetes or epilepsy?
*
Yes
No
15. Have you ever been told that you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that may be made worse by exercising?
*
Yes
No
16. Do you suffer from back or neck pain?
*
Yes
No
17. Do you have pain or restricted movement in any other joints (e.g. hip, knee, ankle, shoulder)?
*
Yes
No
18. Have you been diagnosed as hypermobile (excessive joint mobility)?
*
Yes
No
19. Are there any movements that cause you pain?
*
Yes
No
20. Are you taking any drugs or medication which may affect your ability to exercise?
*
Yes
No
21. Have you been recommended to take up Pilates by a specialist practitioner?
*
Yes
No
21.1. If YES, by your:
*
GP
Physiotherapist
Chiropractor
Osteopath
Other (please state)
*
22. Do you hereby give us permission to contact them?
*
Yes
No
Practitioner's Name
*
Practice Telephone
*
NOW GO BACK UP FOR QUESTION 12...
If you have answered YES to any of questions 3-21 above, we advise that you consult with your medical practitioner before you start Pilates classes. Please give further relevant details below, in confidence, to any questions ticked YES in the box below:
*
Are there any factors that your teacher should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?
*
Part 2: Your Aims
What are your reasons for taking up Pilates?
*
What health or physical goals would you like to achieve over the next 3 months?
*
What longer-term goals would you like to achieve over the next 12 months?
*
Part 3: 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 Pilates 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
Caroline Kinch
Emma Illingworth
Testimonials - Client Feedback
About Pilates
Pilates Background
Back Pain Pilates
More About Low Back Pain
FAQ's
Contact
