Pilates Enrolment Form

Personal Details
Name: *
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
Does your work/sport involve any of the following?
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:
Have you been told by a doctor that you have any heart trouble or defects? *
Do you feel pain in your chest when you undertake physical activity? *
Are you, or could you be, pregnant right now? *
Have you been pregnant in the last 6 months? *
If you have had a baby, please indicate how it was delivered:
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? *
Do you suffer from any of the following:
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? *
Have you been recommended to take up Pilates by a specialist practitioner? *
If yes, by your:
Do you give permission for us to contact your doctor/medical practitioner? *
Exercise History
Do you take regular exercise? *
If yes, please tick the type of session:
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. It is unadvisable to do Pilates between weeks 8 - 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait 6 weeks after the birth before resuming exercise. Pilates exercises are very safe but, as with all forms of exercise, it is prudent to consult with your doctor before starting Pilates sessions. These sessions are not a substitute for medical counselling or treatment. 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 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.