Client Questionnaire — MANOR CLINIC STUDIOS

Today's Date

Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home telephone

Mobile

Emergency Contact - Name

Emergency Contact - Telephone

GP Name

GP Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

HEALTH AND ACTIVITY QUESTIONNAIRE

All information on this form is confidential and please answer truthfully. Your answers will not stop you participating in the class, but the instructor must be fully informed of your medical condition.

Heart problems

Yes

Lung problems

Yes

Asthma

Yes

Diabetes

Yes

Hot swollen joints

Yes

Osteoporosis

Yes

Circulatory problems (DVT, embolus)

Yes

High blood pressure

Yes

Low blood pressure

Yes

Epilepsy (including petit mal)

Yes

Meniere’s Disease

Yes

Detached retina

Yes

Cancer (or benign) tumours

Yes

HIV/Aids

Yes

Multiple Sclerosis

Yes

ME/ chronic fatigue syndrome

Yes

Any other medical conditions

Yes

Have you any joint arthritis or pain that is made worse on exercise?

Yes

Are you currently undertaking any treatment for a back, neck or joint problem?

Yes

Are you pregnant, or had a baby within the last six months?

Yes

Have you been referred by a specialist practitioner?

Yes

If you have answered ‘yes’ to any of the above questions, please give details below:

Are there any movements which cause you pain (arms above the head, bending forwards?)

Please list your present physical activities and any previous experience (including if you teach Yoga/Pilates).

If you have any concerns about your health or suitability for Pilates/Yoga classes, please consult with your doctor prior to participating in this course. Please wear appropriate/comfortable clothing and we ask that you endeavour to be ready to participate in the class on time. Latecomers will miss the warm-up and be at increased risk to injury and it is at the discretion of the instructor as to whether it is safe for you to participate in the class. It is important to always inform the instructor of any problems as a result of a previous class, or any new injuries picked up between classes. If you participate in an equipment class you will undergo a short induction and whilst under instruction we ask you to use the equipment safely, and under the teachers guidance. Use of the equipment is at your own risk. Please note that payment is per block, refunds or adjustments are not possible if you cannot make any dates during that block.

Manor Clinic requires the information on this form in order to identify you in our class and billing database; send you email appointment reminders; send you email term dates and other information about classes; contact you in an emergency and send paper records to your address. By signing below you are giving your consent for us to share your data with our Class instructors and other staff within Manor Clinic unless you advise us otherwise. We will not share your information with any other third parties. We will hold your data indefinitely unless you request it is removed from our database.

By submitting this form, I agree to the following: I comply to the above statement. I declare that the above information is complete and correct. I have read and understood a copy of the Company’s Privacy Statement. I have understood the information regarding the use of the car park and agree that (if applicable) use of the car park is entirely at my own risk.

I have read and agree the above statements

I AGREE

Thank you for taking the time to complete this form.

We look forward to seeing you in class!

Health & Activity Questionnaire

Please complete this questionnaire to ensure that we are aware your current medical status.

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