Prenatal Pilates Consent Form

Name *

First

Last

Address *

Address Line 1

City

State / Province / Region

Postal Code

Mobile No. *

Email *

Date of Birth *

Home Phone No.

Emergency Contact

Emergency Contact Name *

Phone *

Relationship to you *

GP Details

Name of GP (if known)

GP Practice Address *

Address Line 1

City

State / Province / Region

Postal Code

GP Practice *

Pregnancy Details

No. of Weeks Currently Pregnant *

Due to go on Maternity Leave *

Expected Date of Delivery *

Multiple Birth? *

IVF Conception?

Eg. disturbing your sleep

No. of Previous Pregnancies *

(including any not to term)

Planned Location for Birth *

eg. Hospital / Midwife Unit / Home

Name of Midwife (if known)

Under Consultant Care? *

Midwife Contact Details

Healthcare Input During Pregnancy *

Eg. Any illnesses, recent GP visits or if you're under the care of any other healthcare professional / personal trainer / osteopath / chiropractor / massage therapist / acupuncturist etc, please give details

Why do you want to do Pilates?

Exercise: Pre-Pregnancy *

Please give details of the type and frequency of exercise

Exercise: During Pregnancy *

Please give details of the type and frequency of exercise

General Health 1/2

Regular Pain at Night? *

Eg. disturbing your sleep

Recent unexplained weight loss? *

Regular Night Sweats? *

Eg, waking up bathed in sweat, unrelated to the weather

Recent co-ordination or balance changes? *

Eg, tripping over / dropping things, recent falls or feeling unsteady

General Health 2/2

Do you struggle to get into / stay in any of the following positions?

Are you taking any steroid-based medication (or previously taken this type of medication for more than 6 months at a time)? *

Currently taking steroids
Previously on steroids for 6 months or more
No

Are you on any blood-thinning medication? *

Yes
No

eg. aspirin, warfarin

Do you have any allergies? *

Yes
No

Eg. Latex

How much do you drink per week (on average)?

10+ beers / spirits / glasses of wine per week
7 - 10 beers / spirits / glasses of wine per week
3 - 6 beers / spirits / glasses of wine per week
1 - 3 beers / spirits / glasses of wine per week
Don't drink alcohol

Are you currently on any medication? *

Yes
No

Pregnancy Related Health

Please check the relevant box if you experience any of the following and give details in the space below:

Class Details and Consent

Please note

This class is not designed to treat any medical condition or injury you may have. Should you experience any pain or issues during the class, please stop and notify the Physiotherapist.

The Physiotherapist will utilise the information from your health questionnaire and interactions during class, to minimise any risks of pain or discomfort during or after the class, but that this is not always possible to prevent. Should this pain/discomfort significantly impact your everyday life, exacerbate any previous issues or impact your pregnancy, please notify the Physiotherapist in good time, prior to your next session and seek the advice of your Midwife or GP.

The Physiotherapist reserves the right of admission to the class. If they are concerned about the safety of participation, that attendee may be refused admittance (with a refund available at their discretion).

Every effort is made to ensure the equipment used in the class is kept in good condition. Should you need to borrow any equipment from the instructor and you notice any defects in this equipment, please do not use it and notify the Physio immediately.

Please note that the use of resistance bands is optional (hand weights can be used instead) and that there is a risk of the bands snapping. Due to this, we must recommend that protective eyewear (normal glasses do not count) is worn whilst using these to reduce any risk of eye injury. It is at the individual attendee's discretion whether they wish to wear this. Please note that should you wish to utilise such eyewear, it is your responsibility to provide and wear it.

1 *

I agree to inform the instructor of any change to my health, or of any condition that would affect my ability to participate in these Pilates classes, prior to the commencement of a session.

2 *

I understand that it is my responsibility to inform my medical carer that I am participating in Pilates classes and to ensure that I am cleared to do so by my GP/Midwife/Consultant.

3 *

I agree that the health information I have provided is accurate and complete to the best of my knowledge

4 *

I know of no reason why I should not participate in this form of exercise

5 *

I acknowledge that any attendance at subsequent sessions is taken as consent to that session.

6 *

I explicitly consent to the processing of personal and sensitive data I have included in this form and from any interactions with the therapist thereafter, in accordance with the therapist’s privacy policy

Please click here to view our Privacy Policy.

I agree to receive information about upcoming sessions and offers via email or text

I am happy to be included in videos and photos of the session(s) that will be uploaded publicly

Signature *

Date *

On the next page you can view the information you have provided and submit the form

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