New Client Form

Please answer the following questions before taking part in the mat Pilates/Barre/Reformer class. All information will be treated in the strictest confidence and will be used to provide a safe class for you. You are responsible for listening to your body and leaving out any exercise that doesn’t feel right for you.

Name

What would you like to achieve from the classes?

Strong core muscles Better posture Relief from back pain Relief from neck/shoulder tension General toning

Other:

Do you or have you suffered from any of the following? Please tick all that apply:

Heart problems Arthritis Osteoporosis or Osteopenia Back issues Neck issues High/low blood pressure Asthma / respiratory illness Chronic illness

Are you pregnant or post-natal?

Yes - pregnant Yes - post-natal No

Have you had a recent operation or injury?

Yes No

Are you accustomed to physical exercise?

Yes No

Have you been asked not to exercise by a physician?

Yes No

Please give details of any other relevant information here:

COVID-19 Declaration: I understand that I must not attend class if I have symptoms of Covid-19, have been asked to self-isolate or am a close contact of a confirmed case.

I agree to only attend class if the above is true

I am aware that I must inform the instructor of any current or future health issues. I declare that to the best of my knowledge the information above is correct and I know of no reason why I should not participate in the exercise programme. I assume full responsibility for my participation in the class. I release Louisa Fahy, The Pilates Lounge and its instructors from any claims, demands and causes of action as a result of my voluntary participation and enrolment.
Please type your name to show you have read, full understand and agree with this:

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Contact Info

1 Skerries Road Corner, Rush, Co.
Dublin, K56 XK26, Ireland
+353 85 881 8557
info@pilateslounge.ie

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