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Mat Pilates by Ellen - Physical Activity Readiness Questionnaire

Please complete the following questions accurately and to the best of your knowledge to help me to provide classes that are safe, enjoyable and considering the abilities of all participants, regardless of their physical capability and experience. If you have any questions, please do not hesitate to contact Ellen at info@matpilatesbyellen.co.uk or by calling me on +44 7405 176 851. Thank you and I look forward to seeing you in class.

Full name

Age Range

Email address

Contact Number

Emergency Contact Name

Emergency Contact Number

Which Venue/Class(es) are you interested in?

Which Venue/Class(es) are you interested in?

Have you attended a Pilates class before?

Health Declaration

This health form has been designed to identify the small number of people who might need exercises to be modified or who should seek medical advice before joining a Pilates class. Please use common sense when answering these questions.

Do you have a heart condition or have been advised to seek medical advice before starting any physical activity?

Do you have any chest pain when doing physical exercise?

In the past four weeks, have you had chest pain when you were not doing physical exercise?

Do you lose balance because of dizziness or do you ever lose consciousness?

Do you suffer any bone or joint problems that could be made worse by a change in your level of physical activity?

Is your GP currently prescribing you medication for blood pressure or heart issues?

Are you, or is there a chance you could be pregnant?

Do you know of any other reasons why you should not do physical activity?

Is there anything else which you would like to tell your instructor?

Informed Consent

I fully understand that my participation in this activity is completely voluntary and I may withdraw from the exercise class at any time. I also understand that exercise involves inherent but unlikely risk of injury and in extreme circumstances the possibility of death. By signing below I confirm that I have answered honestly and accurately to all of the pre-exercise medical questions and release the instructor from any liability with respect to any damage or injury which I may suffer whilst exercising.

Signature

Signature

Date

Name

GDPR Statement

In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you consent to me retaining your contact details, and to send you information that I think may be useful to you, including events and relevant updates. I only hold information when it is necessary to do so in order for me to carry out my work, and when you have given me permission to do so. I will never share or provide your details to any third party and will treat any details given with full confidentiality. To ensure that I only communicate with you in the manner of your preferred choice, please indicate below, your agreement, or otherwise, to the following means of communication:

I give permission to contact me using the following methods:

I give permission to contact me using the following methods: