Does your work
or sport involve any of the following?
Sitting for long periods
Driving
Bending
Standing
Lifting heavy
weights
Any other repetitive action
1. Has your doctor ever said that you have any sort
of heart trouble or defect?
2.
Have you ever been told
that you have arthritic joint or any bone or joint problem that can be made worst by exercise?
3. Are you pregnant, or have you had a baby in the last 6 months?
4.
Have you had any operations
in the last year?
5. Is there other good reason not yet mentioned that should stop your performing
physical Exercise?
6.
Have you ever had a back
injury?
7.
Are you currently suffering
from backache? If so, do you know why?
8.
Have you ever received
any physical therapy? If so, do you know why?
Describe:
____________________________________________________________________________________
_________________________________________________________________________________________
9. Are there any movements that cause you pain? ( e.g. raising your arms, bending
forward to the side etc.)_________________________________________________________________________________________
10. Do you wish to strengthen a particular area? _______________________________________________
Comments:_____________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________________
Please:
advise the instructor before commencing a class if for any reason your ability to
exercise has changed. It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special
arrangement with the instructor. It is also wise to wait six weeks after the birth before resuming exercise.
Ø All paid classes are non-refundable
and non-transferable except for medical reasons in which case a letter from your doctor must be presented. Please send your check and this form to:
BodyMind Pilates Studio.
