EmailMe Form - PILATES ASSESSMENT FORM

Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code

Email address *

Phone *

Date of Birth *

DD / MM / YYYY

GP name and location. e.g. Dr Smith, Celbridge.

Have you any medical history that is relevant or have you had test that warranted further treatment or review by a consultant? *

Have you any surgical history that is relevant? *

Prescription Medications or Over-the-counter tablets or Herbal or Dietary Supplements: over the past 3 yrs *

Hobbies and Exercise (activity based activities). How active are you currently. Are there limitations to you carrying out certain activities? e.g. kneeling, lying flat? *

Occupation *

What does your Occupation entail? e.g. Manual handling, sitting allot, computer based, driving etc? *

Have you been advised to attend a Pilates or core stability class? If Yes, please give details *

Have you any Pilates experience (incl attending classes, teaching or studying)? Please describe *

Do you experience any bladder or bowel symptoms including incontinence (urine/wind or bowel leaks or urgency or frequency or difficulty going to the toilet) *

How did you get on with the stop and start exercise on the loo (explained in the web link that you accessed this form through) *

Have you problems with your Neck/Back/Pelvis (ache or pain or weakness)? please give details *

What therapies have you had in the past. *

Please provide further information if you have needed to have any therapies. *

Female: Are you planning to get pregnant at the moment? *

Female: If you have children that were born recently, what were their deliveries like? Did you have a section? Did you need stitches or assistance to deliver etc? How have you been since having your baby? Are you able to go for walks without pelvic or back problems?

Female: If you have been pregnant, did you have any pelvic/back/muscle/joint problems?

Have you any Medical legal cases ongoing e.g. after car accident etc *

Yes

No

Are there any other issues that you feel may be relevant when you attend the class or when you practice your exercises at home *

This form was completed on the following date. *

DD / MM / YYYY

Have you arranged your 1-2-1 appointment with Adeline yet. This cannot be done before or after your pilates class as other classees are runnig and needs to be arranged in advanced. *

Yes.

No, I will contact Adeline asap to arrange my 1-2-1

By submitting this form it is assumed that you consent to ALL the following even if you do not check all the boxes. Please state any issues or Questions you have with any the following statements in the box marked OTHER. *

If you are attending another practioner (Physio, GP, Osteopath etc) for an ongoing issue it is essential to speak to them about joining a pilates class that includes mat based stability exercises, using the GymBall as they will know your limitations.

If you need to change your 1-2-1 apt time, please give a minimum of 24hours notice.

Ensure to practice the Pelvic Floor exercise as explained in the weblink

To confirm your space, please bring payment (€100 total) to your 1-2-1 appointment

I will inform Adeline of any changes to my health status incl pregnancy, new pains, new diagnosis etc.

I accept that these Classes are not instructor training courses + I will not use any of the information, advice or the handouts provided to teach anyone Pilates or similar exercises

Adeline O’Dowd/Celbridge Physiotherapy & Hydrotherapy Practice are NOT liable if I teach someone else exercises that I learned in this class or if I give them the handouts/recordings provided to teach themselves or others Pilates

I accept that these classes are non-refundable for any reason.

Please tick here and sign name here