Health Questionnaire

Regular physical activity is fun and healthy. Being more active is very safe for most people however the questions below will highlight if you should be consulting a doctor before taking part in a Pilates exercise class.

Common sense is always a good guide but please read the questions below carefully and answer honestly:

• Has your doctor ever said that you have a heart condition and that you should only do physical activity when recommended by a doctor? Y/N
• Do you feel pain in your chest when you do physical activity? Y/N
• In the past month, have you had a chest pain when you were not doing physical activity? Y/N
• Do you lose balance because of dizziness or do you ever lose consciousness? Y/N
• Do you have a bone or joint problem that could be made worse by a change in your physical activity? Y/N
• Is your doctor currently prescribing you drugs for your blood pressure or heart? Y/N
• Do you know any other reason why you should not do physical activity? Y/N

If you have answered ‘YES’ to any of the above please provide details.

Informed Consent

I, the undersigned, do hereby acknowledge:

My consent to participate in an exercise programme designed by a trained fitness consultant.

My understanding is that exercises will consist of one or more of the following: free body cardiovascular, resistant (strength/endurance) and flexibility

I fully appreciate that there are potential risks involved in participation, e.g. episodes of transient light-headedness or possibly loss of consciousness (highly unlikely) and I assume wilfully these risks

I understand that I may stop or delay any exercise if I so desire and that the class may be terminated by the instructor upon observation of any symptoms of undue distress or abnormal response.

My understanding is that I may ask any questions or request further explanation or information about the procedures at any time before, during and after the training.

That I have read, understood and completed the medical screening questionnaire and obtained medical clearance if necessary.

I hereby sign below to confirm that I provide full consent to participate in the proposed activities and that, by doing so, I accept the risks identified above. I also understand that I may withdraw from the class at any time.