ࡱ> wyv @ fbjbjVV 4zr<r<Pzzzz^4f'(Nta&c&c&c&c&c&c&$(R*X&F"@F"F"& ',%,%,%F"Fa&,%F"a&,%,%%6% ưYz"v%a&6'0f'%8+#8+%8+% L 6,%1!,]! &&d 6D%6Name:  FORMTEXT       Address: FORMTEXT       Postcode: FORMTEXT       Telephone No. (home or work): FORMTEXT       Mobile: FORMTEXT       Date of Birth: FORMTEXT       GP Name & Address:  FORMTEXT       Were you refered here by a medical practitioner? Yes  FORMCHECKBOX  No FORMCHECKBOX  If not, please state how you heard of us: FORMTEXT       Rachel Else Ltds may write to your GP and inform them that you are taking part in the class. Do you give permission for Rachel Else Ltd to contact them? Yes  FORMCHECKBOX  No FORMCHECKBOX   SHAPE \* MERGEFORMAT  PILATES AIMS Have you done Pilates before?  FORMTEXT       Why have you decided to start Pilates?  FORMTEXT       What aspect of your Health would you like to concentrate on? Core Stability  FORMCHECKBOX  Flexibility  FORMCHECKBOX  Posture  FORMCHECKBOX  Toning  FORMCHECKBOX  Stress Management  FORMCHECKBOX  Strength  FORMCHECKBOX  Relaxation  FORMCHECKBOX  Pain relief  FORMCHECKBOX  What are the 3 main aims that you are hoping to achieve in your Pilates program? 1)  FORMTEXT       2)  FORMTEXT       3)  FORMTEXT       LIFESTYLE What is your occupation?  FORMTEXT       Does your occupation involve any repetitive movements or prolonged postures? Yes  FORMCHECKBOX  No FORMCHECKBOX  If yes please give details:  FORMTEXT       What other sports and hobbies are you involved with?  FORMTEXT       HEALTH QUESTIONAIRE 1) Are you currently experiencing any of the following conditions? (if yes, please give details) Low back pain Yes  FORMCHECKBOX  No FORMCHECKBOX  Pelvic pain Yes  FORMCHECKBOX  No FORMCHECKBOX  Neck pain Yes  FORMCHECKBOX  No FORMCHECKBOX  Pain or restricted movement in any other joints? Yes  FORMCHECKBOX  No FORMCHECKBOX  Hypermobility (excessive joint mobility)? Yes  FORMCHECKBOX  No FORMCHECKBOX  Any other spinal conditions Yes  FORMCHECKBOX  No FORMCHECKBOX  Any other orthopaedic conditions Yes  FORMCHECKBOX  No FORMCHECKBOX  Heart problems Yes  FORMCHECKBOX  No FORMCHECKBOX  High or low blood pressure Yes  FORMCHECKBOX  No FORMCHECKBOX  Epilepsy Yes  FORMCHECKBOX  No FORMCHECKBOX  Chest pains Yes  FORMCHECKBOX  No FORMCHECKBOX  Stress incontinence Yes  FORMCHECKBOX  No FORMCHECKBOX  2) Are you pregnant or have you had a baby in the last 6 months? If yes, how many weeks pregnant/post delivery?  FORMTEXT       3) Have you had any complications with your pregnancy? If yes please give details  FORMTEXT       4) Have you ever had and episode of low back pain?  FORMTEXT       5) If yes, how many previous episodes of low back pain have you had?  FORMTEXT       6) Have you had any recent injuries or surgery? If yes please give details  FORMTEXT       7) Check the relevant boxes of any of the following conditions that you have been diagnoses with or have had treatment for Asthma  FORMCHECKBOX  Arthritis  FORMCHECKBOX  Stroke  FORMCHECKBOX  Diabetes  FORMCHECKBOX  Osteoporosis  FORMCHECKBOX  Depression  FORMCHECKBOX  Bronchitis  FORMCHECKBOX  Cancer  FORMCHECKBOX  Dermatis  FORMCHECKBOX  Osteopenia  FORMCHECKBOX  8) Do you have any other medical conditions not mentioned above?  FORMTEXT  "$&024DFZ\^hj , . 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(e.g. raising your arms, bending forward or to the side etc.)  FORMTEXT       11) Do you suffer from stress incontinence? FORMTEXT       PILATE PARTICIPANT INFORMED CONSENT The Pilates program will begin at a low level and will be advanced in stages depending on your fitness level. We may stop the exercise session because of signs of fatigue and/or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any discomfort. There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body s exact response to exercise. Every effort will be made to minimise risks by evaluating the preliminary information relating to your health and fitness and by observing you exercising. As with all forms of physical exercise, it is prudent to consult your doctor before starting classes, we particularly recommend this if you have any doubts about your health or suitability to do the exercises. Exercise should be performed at a pace which feels comfortable for you. PAIN is the body s warning system and should NOT BE IGNORED. Please inform your instructor immediately if you feel any discomfort during a session. Please also inform your instructor if you felt any discomfort after a previous session. I confirm that I have read and understood the above advice and that the information I have given is correct. Signed FORMTEXT       Date  FORMTEXT     Please return to: Rachel Else Ltd, 74 Tarnwood Park, Eltham, London, SE9 5PB along with your cheque for 50. Cheques should be made payable to  Rachel Else Ltd . Forms can be returned by e-mail to  HYPERLINK "mailto:info@rachel-else.co.uk" info@rachel-else.co.uk and payments can be made by bank transfer: Account name Rachel Else Ltd, the sort code is 72-00-00 and the account number is 01270761 (please put your name as a reference so know who has sent the money). 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