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A painless body that performs well. This is what we do.

FORMS

For our newest clients. Please fill out, sign and submit the form.

To add your signature please hold your finger down on the mousepad while signing.

Thank you!

Name *

First

Last

Date

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Email *

Emergency Contact

Emergency Contact phone number

How did you hear about us?

Have you done Pilates before?

Yes
No

If yes, please give details...

What are you hoping to achieve from your Pilates experience?

MEDICAL QUESTIONAIRRE

1. High or low blood pressure?

Yes
No

If yes, please specify and indicate the affect on your ability to move/exercise.

2. A heart condition?

Yes
No

If yes, please specify and indicate the affect on your ability to move/exercise.

3. Arthritis?

Yes
No

If yes, please specify where in the body.

4. Osteopaenia / osteoporosis?

Yes
No

If yes, please specify where in the body.

5. Asthma?

Yes
No

If yes, please specify and indicate current treatment.

6. Panic attacks?

Yes
No

If yes, please specify and indicate current treatment.

7. Sleep apnoea or other breathing problems?

Yes
No

If yes, please specify and indicate current treatment.

8. Spinal/neck condition?

Yes
No

If yes, when was your last bone scan?

10. Diabetes or epilepsy?

Yes
No

If yes, please specify if you are on medication and well-controlled.

11. Any form of cancer?

Yes
No

If yes, please specify:

12. Autoimmune condition?

Yes
No

If yes, please specify:

13. Digestive problems?

Yes
No

If yes, please specify:

14. Have you had any type of surgery this year or any significant surgery in the past?

Yes
No

If yes, please specify:

15. (Women only) Have you given birth?

Yes
No
Not a woman

If yes, please specify:

16. Any concerns regarding hernia, reflux, incontinence and/or Pelvic Floor function?

Yes
No

If yes, please specify and indicate the affect on your ability to move/exercise.

17. Are there any other conditions not covered in the above?

Yes
No

If yes, please specify:

MOBILITY QUESTIONAIRRE

If you were lying on the floor how easy would you find it to get up by yourself without help?

Very easy, could do it without using hands and arms.
Easy, but would use my hands and arms.
Not sure, might need help of someone or something to lean on. Would be a struggle.
Difficult, probably would need help of someone or something.
Very difficult, would definitely need help from someone. Would need help to lift me.

If you had the choice of 3 flights of stairs or an elevator to access your Pilates class, how likely would you be to choose the elevator?

Definitely choose elevator
Probably choose elevator
Depends on the day
Probably choose stairs
Definitely choose stairs

TERMS & CONDITIONS - PLEASE READ CAREFULLY

All sessions are by appointment only
All sessions are for 1-hour
All classes must be pre-paid
All classes are non-refundable and non-transferable
Full fee will be charged for less than 24-hours notice of cancellation
TPCM has the right to cancel classes at any time
All payments are valid for 6 months only
All person who attend The Pilates Centre Mosman do so at their own risk
I have read and agree to the above Terms & Conditions

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