Beginners Pilates
Physiotherapy assessment form for Pilates
Email *
Please fill in this form in advance of your class so that I can prepare for each person's needs.

All you need to bring with you is a drink & a mat or large towel that you don't mind using on the floor. A pillow or cushion for your head or an extra towel is also recommended.

There will be people at many different levels in the class. I will provide different difficulty levels for exercises so please stay at the one that feels safe for your ability and pain free. If you experience any discomfort or do not feel safe during the class please stop & inform me immediately. I am a Physiotherapist & make it my mission to help everyone have a positive movement experience minimising risk & educating my clients.

If you have any awareness of your symptoms: pain, dizziness, shortness of breath, heart palpitations, pelvic floor symptoms or any other muscle or skeletal pains during the class, stop & tell me immediately please.

If you have any questions, please feel free to email me at epilatesclinic@gmail.com and title it 'Beginners Pilates.

The class will run for 50 minutes. 

Thanks,

Emma Fitzmaurice 
epilatesclinic
Name *
Today's date *
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Date of Birth *
Phone number *
Email address *
Address *
In case of emergency contact *
Number of children & age of each ( twins?) *
Births
GP Name, address & phone number *
How is your general health? Please give details of any medical conditions you may have in general *
Current exercise level *
Required
Have you had any previous investigations or operations. Pease give dates & the name of hospital attended. ( x-rays, MRI's) *
Current & past injuries (including aches & pains) & history of that pain. *
onset date, how it started, treatment, medication required, if it interferes with day to day activities/ work
Today's date *
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YYYY
Location's of pain for scale *
Level of current pain
0 is no pain & 10 is the worst physical pain ever
no pain
worst pain
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Current medication  *
Precautions. Please tick all applicable

 *
Required
I have, to the best of my knowledge, given an accurate representation of my medical condition/s and exercise ability, and have made a note of any conditions that the physiotherapist will need to be aware of *
Required
I agree to inform the Physiotherapist of any change to my health, or of any condition that would affect my ability to participate in these sessions, prior to the commencement of a session. I am aware that failing to disclose pertinent information may hinder the Physiotherapists ability to provide the most effective and safe treatment. *
Required
I understand that if the Physiotherapist is concerned about your safety in the class, you will be asked to seek medical clearance in writing prior to participation *
Required
Please tick if you agree *
Required
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