* Denotes required fields
Title *
First Name *
Surname *
Occupation *
Date of Birth *
Address *
Your email *
Mobile Number *
Emergency Contact Name *
Emergency Contact Number *
Has your doctor ever said that you have a heart condition and that you should only do exercise recommended by your doctor? YesNo
In the past month, have you had chest pain when you are not doing physical activity? YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity? YesNo
Are you diabetic? YesNo
Are you taking any medication? YesNo
Do you feel pain in your chest when you do physical activity? YesNo
Do you lose your balance because of dizziness or do you ever lose consciousness? YesNo
Is your doctor currently prescribing drugs for your blood pressure or heart condition? YesNo
Do you have a chronic cough or a condition that affects your breathing (hayfever, asthma?) YesNo
Do you know of any other reason why you should not do physical activity? YesNo
Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise. *
Please provide any further information related to the prior issues here, if applicable.
If you have answered “yes” to one or more of the questions above, you should consult with your doctor to clarify with your doctor that it is safe for you to participate in physical activity at this time. Please tick the box to advise if you have done this YesNo
I have ticked “NO” to all of the above questions OR, I have consulted with my doctor who has confirmed it is safe for me to participate in physical activity at this time.*
I have read, understood, and accurately completed this questionnaire. I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.*
I understand that this form is valid for 12 months and becomes invalid if my condition changes. I understand that it is my responsibility to inform Sarah Gatford Pilates of such changes.*
I have read and understood the liability waiver. *
