Health Questionaire

First name

Last name

Email

Birthday

Day

Month

Year

Phone

Address

Emergency contact name / relationship

Emergency contact number

Please tick if you currently or have previously suffered with any of the following (required)

Chestpain

Heart Disease

High Blood pressure

Low Blood pressure

Blood disorder

Epilepsy

Diabetes

Hypoglycaemia

Shortness of breath / asthma

Allergies / hay fever

Arthritis

Muscular injuries

Ankle pain / injuries

Knee pain / injuries

Back problems / pain

Neck problems / pain

Pelvic problems / pain

Shoulder problems / pain

Wrist problems / pain

None of the above issues

Please give details including dates, medical treatment received and medications taken (required)

Have you had surgery in the past year? (required)

Yes

No

Are you currently under the care of a health professional? Doctor, Consultant, Physiotherapist etc

Have you ever been advised to avoid physical activity?

Yes

No

Are you currently pregnant? (required)

Yes

No

If yes has your Midwife or other Medical professional given you the all clear to participate in physical activity?

Yes

No

Is there anything else you can think of that may affect you attending Pilates , Yoga and reformer sessions?

ASSUMPTION OF RISK

I acknowledge that participation in Pilates, yoga, barre, reformer Pilates and all other exercises classes involves physical exercise and activity that can be strenuous and may lead to injury. I understand that it is my responsibility to consult with a physician before participating in any exercise program or activity, including reformer Pilates. I assume all risks associated with participating in these classes, including but not limited to, muscle strains, joint injuries, or any other physical injury.

RELEASE OF LIABILITY

In consideration of being allowed to participate in Mauré Studios classes, I hereby waive, release and discharge Mauré Studios, its owners, employees, instructors and agents from any and all claims, demands, liabilities, or causes of action arising out of or related to any loss, damage, or injury that may be sustained by me, whether or not caused by the negligence of Mauré Studios or its representatives.

PERSONAL RESPONSIBILITY

I agree to follow the instructions provided by the instructor and to use the equipment in a safe and responsible manner.

MEDICAL CLEARANCE

I confirm that I am in good health and have no medical conditions that would prevent me from participating in a Mauré studios classes involves. I understand that it is my responsibility to inform Mauré Studiod of any medical conditions or injuries that may affect my participation.

Signature

Signature field is empty.

Date of signature

Day

Month

Year