Client Information FormPlease complete the form below prior to your first session. Thank you, I am looking forward to seeing you soon!Please note all information is handled with strict confidentiality. Name * First Name Last Name Email * Contact number * Date of Birth * dd/mm/yyyy How did you hear about FIT HIIT Pilates? Google Facebook Newspaper Radio Flyer/business card Other If other, please specify Occupation * Emergency Contact Details * First Name Last Name Contact Number * Relationship to Emergency Contact * Do you have any medical condition? * Yes No If yes, please share details Do you have any allergies * Yes No If yes, please list Current health conditions (tick all that apply) Asthma Diabetes High blood pressure Low blood pressure High Cholesterol Heart Conditions Epilepsy Dizziness Chest Pain Arthritis Osteoporosis Other (please specify) Current injuries and treatment Previous injuries and treatment Do you take any medication that may affect you while exercising? Yes No If yes, please expand Have you ever had undiagnosed pain in the following areas? (please tick all that apply) Ankles Knees Hips Lower back Upper back Neck Shoulders Elbows Wrists If you ticked any of the above, please expand Are you pregnant? Yes No If yes, what is your due date? dd/mm/yyyy Please include any additional pregnancy information Do you currently exercise? Yes No If yes, what is the frequency and intensity? What are your goals? Core strength Glute strength Overall muscle tone & strength Flexibility Balance Mobility Improved posture Connect with yourself Other If other, please share details Is there any other condition or disability not covered above that your Pilates instructor should be aware of? Yes No If yes, please expand Informed consent and waiver of liability * I am participating voluntarily in FIT HIIT Pilates. I understand that the instructions provided throughout the classes are intended as guidance, and will faithfully follow all instructions given to me by FIT HIIT Pilates, Evolve Airlie and their associated teachers. I agree and acknowledge that participation in any pilates exercises could constitute a risk of serious injury to myself, and I voluntarily and knowingly recognise, accept and assume this risk and warrant that I am physically fit and able to perform the pilates exercises. FIT HIIT Pilates, Evolve Airlie, associated teachers, staff or employees are not liable for, nor are expected to provide any advice, training or medical assistance other than in the form of pilates exercises. You must inform your instructor about any change in your medical condition as soon as you become aware of it. I agree that the information I have given on this document is true and correct. I have read and understood all wording printed on this document and take full responsibility for my actions at all times at FIT HIIT Pilates and Evolve Airlie. In ticking below, I indemnify FIT HIIT Pilates, Evolve Airlie, associated teachers, staff or employees of FIT HIIT Pilates and Evolve Airlie, from and against all actions, suits, causes of action, proceedings, claims, costs and expenses whatsoever in connection with or arising out of any injury, illness or mishap. I accept the terms and conditions and agree to abide by them Thank you!
