Name
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First Name
Last Name
Email
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Phone
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(###)
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Suburb
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Occupation
Medical History. Have you had a major surgery, fractured or broken bones, dislocated joints or sustained other serious injuries in the past five years? If yes, please detail what and when.
Do you experience any of the following? please check all that apply
Do you experience a chronic health condition(s) that affects your physical movement in any way? If so, please specify.
What is your main motivation in coming to reformer pilates 1:1 sessions? what are your goals? eg. strength, rehab, posture, performance. give us an idea of why you're here.
what are your previous (past five years) and current exercise habits? do you presently play sport (if so, specify your level), hike, run, swim etc?
Have you used a Pilates reformer before? If so, how would you describe your level of understanding and confidence on the machine?
Have you practiced mat Pilates?
Are you currently pregnant? If yes, when is your estimated due date?
Are you returning to movement postnatally? If yes, what's your youngest child's DOB?
I confirm by submitting this form that I understand the instructions given during class are intended as guidance and it is therefore my responsibility to adjust my practice according to my ability, to ensure no injury occurs, and inform the teacher prior to class of any changes in my physical condition.
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I confirm that I release Grounded Yoga & Pilates of responsibility from any injury sustained during these sessions and that I take full responsibility for my physical & psychological well being.
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Date submitted
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