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Fitness Pilates Health Screening Form

Name: ……………………………………………………………………………………………………….............................

 

Address: …………………………………………………………………………………………………………………………..

Contact Number: ……………………………………….……………………      Date of Birth: ……./……../………….

Email address:……………………………………………………………………………………………………………………..

● Do you suffer from back problems?    YES / NO.   If yes, please give details:…………………………………….

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● If you have back problems now, are you receiving treatment from :

- Physiotherapist  YES / NO  If so, please give name and contact number: …………………………………………...

  ………………………………………………………………………………………………………………………………………

- Chiropractor   YES / NO  If so, please give name and contact number: ……………………………………….

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 - Osteopath   YES / NO  If so, please give name and contact number: …………………………………………

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 - Any other professional   YES / NO  If so, please give name and contact number:………………………………..

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● Have you ever had treatment for a back problem?    YES / NO   Details: ……………………………………

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● Have you been given medical clearance to attend a Fitness Pilates Class?    YES / NO

● Are you suffering from any other medical problems that may affect your ability to exercise? -

   YES /NO   Details: …………………………………………………………………………………………………………….

 

● Have you any additional Health information that may be relevant?  YES / NO   Details: ………………..

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● How do you rate your overall posture – give details:

  Excellent: ………………………………………………………………………………………………………………………..

  Average: ………………………………………………………………………………………………………………………….

  Poor: ……………………………………………………………………………………………………………………………… #

 

  Very poor: ………………………………………………………………………………………………………

Health and Fitness Declaration:

I understand that whilst every care will be taken to give safe instruction, I accept full responsibility and consider myself fit to exercise.  I have answered all the questions correctly and all medical and health considerations are noted above.  I understand that I attend Fitness Pilates classes at my own risk.  I will keep the instructor updated.

Signed: ………………………………………………………………………………                      Date: ……/……/………….