Questionnaire

Please provide Name & Telephone Number to be used in case of emergency
Does your work/sport involve any of the following?
Will this be the first time you practiced Pilates?
If No, have you previously attended?
Do you feel pain in your chest when you undertake physical activity?
Are you or could you be pregnant now?
Have you been pregnant in the last six months?
If you had a baby how was it delivered
Do you often get headaches?
Do you lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy?
Do you have high blood pressure
Have you had major surgery in the last 10 years?
Have you had minor surgery in the last 2 years?
Do you suffer from asthma, diabetes or epilepsy?
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?
Do you suffer from back or neck pain?
Do you have pain or restricted movement in any other joints (i.e.: hip, knee, ankle, shoulder)?
Have you ever been diagnosed as hyper mobile (excessive joint mobility)?
If you have answered ‘yes’ for questions 14-18, do you have medical permission to exercise?
Are there any movements that cause you pain?
Are you taking any drugs or medication which may affect your ability to exercise?
Have you ever been recommended to take up Pilates by a specialist practitioner?
Do you hereby give us permission to contact them?

Please advise us before commencing any session if, for any reason, your health or your 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 warning system and should not be ignored. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session.
I understand that PILATES WITH DORITA exercises involve hands-on correction and I hereby consent for my teacher to work in this way.
I confirm that I have read and understood the above advice and that the information I have given is correct.
I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information:
· will be used in confidence and stored securely
· will not, in any circumstances, be shared with a third party without my written consent, unless that party is another (Body Control) Pilates teacher who will teach me.
· may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfill.
I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities and understand that I have the right to withdraw this ‘consent to be contacted’ at any time.

Agreement *