Enrolment Form - Mind Body Golf

Client Enrolment Form

All information will be treated in the strictest of confidence.

PERSONAL DETAILS:

Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Preferred Contact Tel No

Email *

Sex

Male
Female

Date of Birth

Occupation

Sports / Hobbies

Please provide any information in relation to any Sports or Hobbies that you have.

EMERGENCY CONTACT DETAILS:

Emergency Contact Name *

Emergency Contact Tel No

Emergency Contact Email *

PART 1 – YOUR BACKGROUND AND YOUR HEALTH

2. WILL THIS BE THE FIRST TIME THAT YOU HAVE PRACTISED PILATES?

3. HAS YOUR DOCTOR EVER SAID THAT YOU HAVE ANY SORT OF HEART TROUBLE OR DEFECT?

4. DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU UNDERTAKE PHYSICAL ACTIVITY?

5. ARE YOU, OR COULD YOU BE PREGNANT NOW?

6. HAVE YOU BEEN PREGNANT IN THE LAST SIX MONTHS?

7. IF YOU HAVE HAD A BABY, HOW WAS IT DELIVERED?

Normally
Caesarean
Normally with intervention (eg. Forceps)

8. DO YOU OFTEN GET HEADACHES?

9. DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS, FEEL FAINT OR DIZZY?

10. DO YOU HAVE HIGH BLOOD PRESSURE?

11. IS YOUR BLOOD PRESSURE:

Normal
Low

12. HAVE YOU HAD MAJOR SURGERY IN THE LAST 10 YEARS?

13. HAVE YOU HAD MINOR SURGERY IN THE LAST TWO YEARS?

14. DO YOU SUFFER FROM ASTHMA, DIABETES OR EPILEPSY?

15. HAVE YOU EVER BEEN TOLD YOU HAVE ARTHRITIC JOINTS, OSTEOPOROSIS, OSTEOPENIA OR ANY BONE OR JOINT PROBLEM THAT MAY BE MADE WORSE BY EXERCISING?

ARTHRITIC HAVE YES,

16. DO YOU SUFFER FROM BACK OR NECK PAIN?

17. DO YOU HAVE PAIN OR RESTRICTED MOVEMENT IN ANY OTHER JOINTS (EG: HIP, KNEE, ANKLE, SHOULDER)?

18. HAVE YOU EVER BEEN DIAGNOSED AS HYPERMOBILE (EXCESSIVE JOINT MOBILITY)?

19. ARE THERE ANY MOVEMENTS THAT CAUSE YOU PAIN?

20. ARE YOU TAKING ANY DRUGS OR MEDICATION WHICH MAY AFFECT YOUR ABILITY TO EXERCISE?

21. HAVE YOU EVER BEEN RECOMMENDED TO TAKE UP PILATES BY A SPECIALIST PRACTITIONER?

22. DO YOU HEREBY GIVE US PERMISSION TO CONTACT THEM?

Additional Information

Please list any health problems you suffer, not already mentioned, that may affect your ability to exercise. If you have answered YES. to any of questions 3-21 above, we advise you consult with your medical practitioner before you start Pilates Classes. Please give further relevant details below, in confidence, to any questions you ticked YES. Are there any factors your teacher should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?

Additional Details

PART 2 – YOUR AIMS

23. WHAT ARE YOUR REASONS FOR TAKING UP PILATES?

24. WHAT HEALTH OR PHYSICAL GOALS WOULD YOU LIKE TO ACHIEVE OVER THE NEXT THREE MONTHS?

25. WHAT LONGER-TERM HEALTH OR PHYSICAL GOALS WOULD YOU LIKE TO ACHIEVE OVER THE NEXT 12 MONTHS?

PART 3 – IMPORTANT INFORMATION

Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes.

It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise.

Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions.

These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. The teacher can accept no liability for personal injury related to participation in a session if:

Your doctor has, on health grounds, advised you against such exercise.
You fail to observe instructions on safety or technique.
Such injury is caused by the negligence of another participant in the class/studio.

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 teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session.

I understand that Body Control Pilates exercises involve hands-on correction and I hereby consent for my teachers to work in this way. I confirm that I have read and understood the above advice and that the information I have given is correct.

Your Signature

Clear Signature

Your Name

Type your full name here

Todays Date

PERSONAL DETAILS:

EMERGENCY CONTACT DETAILS:

PART 1 – YOUR BACKGROUND AND YOUR HEALTH

Additional Information

PART 2 – YOUR AIMS

PART 3 – IMPORTANT INFORMATION

Teacher: Paul Moultrie

4 VICTORIA DRIVE

TROON

BOOKINGS BY

APPOINTMENT

Phone: 07447 776 700

INFO@MINDBODYGOLF.CO.UK