Pilates Intake form and waiver of liability : Live By Living

*Your name

*What is your birth date?

*Your email

*Phone

Emergency contact name

Emergency contact phone number

*Have you taken Pilates classes before?

Yes No

*What do you hope to get out of taking Pilates?

*If you checked any of the medical conditions, please explain, including dates of any diagnosis/treatment. If you checked none, just write "none."

*Are you pregnant?

Yes No

*Has your doctor ever listed your physical activity because you have a heart condition?

Yes No

Please explain what activty limitations your doctor recommended for you due to your heart condition.

*Do you ever feel any chest pain when you do physical activity?

Yes No

Please explain

*In the past month, have you had any chest pain when you were NOT doing physical activity?

Yes No

Please describe your chest pain

*Do you ever lose your balance because you get dizzy?

Yes No

Please describe instances when you lose your balance due to dizziness

*Has your doctor ever limited your physical activity because of a joint or bone problem, like osteoporosis or osteopenia?

Yes No

Please explain andy limits your doctor put on your physical activity because of joint or bone problems

*Are you on any medication for your blood pressure or any cardiac condition?

Yes No

What heart/blood pressure medications are you on?

*Are you aware of any other reason you should not engage in physical activity?

Yes No

Please explain any other reasons you should not engage in physical activity

*Has your doctor ever told you to limit your physical activity because you have lymphedema?

Yes No

please explain any limits on your physical activity your doctor imposed because you have lymphedema

BY SIGNING BELOW, I CERTIFY THAT I HAVE GIVEN FULL AND COMPLETE DISCLOSURE OF ALL PHYSICAL CONDITIONS, LIMITATIONS, DISEASES, INFIRMITIES, AND/OR ILLNESSES THAT MAY AFFECT OR PREVENT MY PARTICIPATION IN THE PILATES CLASSES.

I have completed the medical screening questionnaire and have fully disclosed to Pilates Plus, LLC all my injuries and illnesses past and present. I agree to let Pilates Plus, LLC know immediately if my physical condition changes. I also understand that a medical evaluation is advisable before commencing any program of physical conditioning or exercise. I acknowledge that, although the conditioning program I participate in may have substantial physical benefits, neither Pilates Plus, LLC nor its independent contractors are engaged in diagnosing or treating medical diseases or deficiencies.
I understand that I have enrolled in a program of instruction in the Pilates method of physical conditioning offered by Pilates Plus, LLC. I have been advised and I understand that participating in Pilates method exercise and conditioning activities, like any physical conditioning activity or exercise program, presents some unavoidable risk of injury, especially to people who have pre-existing injuries, illness, or medical disabilities. I understand that the use of exercise equipment and/or participation in the online classes carries with it a risk of injury. I recognize that many changes may occur as a result of exercise lessons, including the possible short-term aggravation of some symptoms, feelings of tiredness, light headedness, muscle soreness, etc.
I expressly assume all risks of my participating in the programs conducted at Pilates Plus, LLC and waive any claim that I might otherwise bring against Pilates Plus, LLC, its officers, employees, independent contractors, and Live By Living as a result of injuries resulting from or relating to my participation in Pilates method conditioning programs.
This Waiver of Liability and Informed Consent Release shall bind me and all affected heirs, successors, and assigns.
I understand that all classes require a prior evaluation of my fitness level and that I am responsible for attending the appropriate level class.

I HAVE READ AND UNDERSTAND THIS WAIVER OF LIABILITY AND INFORMED CONSENT RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER.

*Please sign here using your mouse or touchpad.

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