Health Questionnaire

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Email *

Full Name

Time & Date of FREE taster

Date of Birth / Age?

Mobile number?

Next of Kin Details and contact number?

Address?

What are your hobbies?

What is your occupation?

Do any of the following apply to you NOW or in the past?

Heart issues including chest pain

High / Low blood pressure

Epilepsy

Joint issues

Respiratory issues

Majory surgery

Hip / Knee Replacements

Dizziness or lose consciousness

Pregnant or recently had a baby?

Fibro, ME or any other Morbidity

Neck or Spine

Other:

If you have said YES to any of the above, please can you provide more information and let us know if you are on any medication for your conditions.

If you have answered YES to any of the above questions, has your doctor confirmed that it is OK for you to do any form of exercise?

Yes

Clear selection

If you have answered NO to all of the above questions can you confirm that there are no other issues I need to be aware of and consider yourself to be healthy enough to take part in an exercise class?

I hereby state that I have read, understood and answered honestly the pre-exercise health screening questionnaire. Any questions I had were answered to my full satisfaction. Whilst every effort is made to keep the class safe and enjoyable, I am participating of my own free will and as with any exercise programme there is a risk of injury. I understand that on rare occasions there may be a stand-in teacher

Yes

Clear selection

There may be times when we might need to use hands-on adjusting to help you into the correct position/form during an exercise. Do you consent to ourselves, and any other cover instructor we may have to help you in this manner?

Yes

Clear selection

We love to share photos/videos on marketing materials such as social media/website videos to help encourage other people to try our services. There are times that we will take videos or photos of a class in progress. Do you consent to allow photos/videos to be taken and used for our marketing?

Yes

Clear selection

GDPR: I confirm that the above information I have given is correct to the best of my knowledge. I consent to Elite Pilates Services processing my personal data in accordance with the General Data Protection Regulation 2018. My contact details will only be used by Elite Pilates Services third parties, without written consent from me.

Yes

Clear selection

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