Ante + Post Natal Pilates Enrolment Form

Personal Details
Name: *
Name:
Address: *
Address:
Please ensure you fill in each line of your address.
Date of Birth: *
Date of Birth:
Emergency Contact Details:
Emergency Contact Name:
Emergency Contact Name:
Your Background + Your Health
Doctor's Name: *
Doctor's Name:
Do you give permission for us to contact your doctor/medical practitioner? *
Antenatal Clients only
Name of midwife/doula:
Name of midwife/doula:
Due date of your current pregnancy:
Due date of your current pregnancy:
Please tick which trimester you are currently in
Has your doctor or midwife given you medical clearance to take part in exercise? *
Ante + Post Natal Questions
Please indicate the methods of delivery for these children:
Have you ever experienced any of the following, past or present?
Have you ever suffered with Pelvic Girdle Pain e.g. symphysis pubis dysfunction, sacroiliac joint pain?
Do you lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy? *
Is your blood pressure: *
If your answered high, is it being medically controlled?
Have you had major surgery in the last 10 years? (except Caesarean section) *
Have you had minor surgery in the last two years? *
Have you ever been told that you have arthritic joints, osteoporosis or any bone or joint problem that may affect your ability to exercise? *
Do you have neck or back pain? *
Do you have pain or restricted movement in any other joints? (e.g. hip. knee, ankle, shoulder) *
Have you been diagnosed as having hypermobile joints? *
Are there any movements or positions which cause you pain? *
Is there anything else in your medical history that you feel could affect your ability to exercise? *
Are you taking any medications that may affect your ability to exercise? *
Postnatal Clients Only
Did you have a lengthy or difficult labour?
Method of delivery of your recent baby:
If you had a vaginal delivery, did you have any stitches to repair an episiotomy or tear?
If yes, have you healed?
Are you breastfeeding?
Do you have any particular concerns or worries about exercise in the postnatal period?
Has your doctor, consultant or midwife given you medical clearance to take part in exercise?
Exercise History
Do you take regular exercise? *
If yes, please tick the type of session:
Will this be the first time that you have practised Pilates? *
If no, please indicate the type of Pilates your have done before:
Please indicate the number of classes attended:
Your Aims
Important Information
I understand that Clifford Studios Pilates exercises involve hands on correction and I hereby consent for my teachers to work in this way. I confirm that I have read and understood the advice below and that the information I have given is correct. *
Please advise us before commencing any session if, for any reason, your health or ability to exercise changes. If you are pregnant, we strongly recommend that you check with your doctor/midwife at regular intervals (perhaps at your antenatal check ups) if it is still ok for you to exercise. If you are in doubt about the suitability of the exercises, please 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 not given you medical clearance to exercise/to 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 The exercises, and the transitions between exercises, should be performed at a pace which feels comfortable for you. Please tell the teacher if you feel any discomfort, dizziness, nausea or pain during the session. Please also inform the teacher if you felt discomfort or pain after a previous session.