Personal Details & Screening Form Name * First Name Last Name Email * Age * Date of Birth * MM DD YYYY Email * Mobile Phone Number * Home Address * GP/Doctor's NUMBER or Emergency contact NUMBER * SCREENING FORM Please answer Yes or No and detail where necessary Are you currently taking ANY medication? * Yes No If you are on, or just coming off, medication then please detail below, including any relevant information that may impact your safety. Are you pregnant or have given birth in the last 3 months? * Yes No Please detail any specifics regarding pregnancy/birth that may impact your safety Is there a history of heart problems or chest pain in your family or with you? * Yes No If so then please detail below Do you have HIGH or LOW blood pressure? * Yes - High Yes - Low No Do you have difficulty with physical exercise or advice from your GP to avoid specific movements? * Yes No If so then please detail below Do you have Diabetes? Yes No If so then please detail below Do you have any muscle, joint or back disorders that could be aggravated by physical exercise? * Yes No If so please detail Have you a recent surgery? (within last 3-6 months?) * Yes No If so please detail Do you have Asthma or trouble breathing? * Yes No If so please detail below Do you have ANY chronic illness? * Yes No If so please detail Do you have high blood cholesterol levels? Yes No Do you ever feel faint, dizzy or light-headed? Yes No If so please detail Do you have any conditions that will prevent you from performing exercises ranging from high impact moves, running, pressing, lifting and an elevated heart rate? Yes No If so please detail below If you have answered YES to any of the above, or have any other information to disclose regarding your health orr injury history please detail here and we will speak to you before your class/training commences. It is also worth noting that the more you let us know regarding pain, aches, trauma etc the more we will know to help you with By signing this you agree * 1. You have read, understood clearly and agree to the points outlined in Covid 19 Protocols. 2. You agree to proactively look after your personal cleanliness, hygiene with regards to washing hands, sanitising appropriately, and to cover your mouth into your elbow if coughing/sneezing. 3. You agree to maintain social distancing within the studio (according to guidelines at that time), understanding that, although we will spend the majority of class in our designated training space, people might will be moving around [water station/toilet],. The principle to respecting navigating space around others is of the utmost importance. 4. You agree that as of now you are Covid-19 symptom-free, AND that you, to the best of your knowledge, have not been around anybody or are in close contact with anybody who has any Covid-19 symptoms 5. That all the information above is correct as of todays date and that if there are any changes to your health you will notify us and you are also agree to the following: We strongly recommend that you consult with your physician before beginning any exercise program.You should be in good physical condition and be able to participate in the exercise. We are not licensed medical care provider and represent that is has no expertise in diagnosing, examining, or treating medical conditions of any kind. or in determining the effect of any specific exercise on a medical condition. You should understand that when participating in any exercise or exercise program, there is the possibility of physical injury. If you engage in this exercise or exercise program, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge pilatesroom.ie and Simply Movement from any and all claims oro causes of action, known or unknown, arising out of pilatesroom.ie and Simply Movement negligence. First Name Last Name Todays Date * MM DD YYYY Thank you!
