New Client Registration - Post natal

Post-natal registration and health questionaire

Please complete this form before attending your first post-natal pilates class or course

Personal details:

First name

Last name

Address

Date of birth

Day

Month

Year

Phone

Email

GP name and surgery

Next of kin name and phone number

Par-Q:

Has your doctor ever said that you have a heart condition OR high blood pressure?

Yes

No

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes

No

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Yes

No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

No

If yes please give further detail

Are you currently taking prescribed medications for a chronic medical condition?

Yes

No

If yes please list medications here

Do you currently have (or have had within the past 12 months) a bone, joint, OR soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?

Yes

No

Please list conditions here:

Has your doctor ever said that you should only do medically supervised physical activity?

Yes

No

Post natal health:

Date baby was born

Day

Month

Year

How many weeks post-natal are you?

How did you give birth?

Vaginal

Planned C-section

Emergency C-section

Did you have any complications during pregnancy, birth or after the birth?

Did you have an Episiotomy?

Yes

No

Are you currently breast-feeding?

Yes

No

It is important that you keep the class instructor up to date with any changes to your health during your attendance at pilates classes and you must stop exercising and notify the instructor immediately if you feel unwell or in pain. If you choose to bring your baby along to class they remain your responsibility throughout the class.

I understand

Your personal and health information will be stored securely in line with GDPR. Please see the privacy policy on this website for more information. Class reminders and booking confirmations will be sent out by email, you can opt out of this at any time by contacting us.

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No refunds will be given for class cancellations with less than 24hours notice. You may reschedule a class to an alternative date up to 24hours before your booking. For the Post natal Foundation course 48hrs is required for cancellations and rescheduling.

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