Name *

Prénom

Nom de famille

Mobile *

Pays

(###)

###

####

Address *

Adresse 1

Adresse 2

Ville

Région/Province

Code postal

Pays

Date of birth *

MM

JJ

AAAA

1. Has your doctor ever said that you have any sort of heart trouble or defect? *

NO

YES

2. Is there any part of your medical history that we should be aware of, or that might affect your ability to perform certain exercises (e.g., asthma, dizziness, chest pain, etc.)? *

NO

YES

3. Have you had any operations or injuries in the last year? *

NO

YES

4. Do you suffer from backache? *

NO

YES

5. Have you ever been told that you have arthritic joints or any bone or joint problem that may be made worse by exercise? *

NO

YES

6. Are there any movements or areas of the body that cause you pain (e.g., raising your arms, bending forward or to the side, etc.)? *

NO

YES

7. Have you ever been given any remedial exercises? *

NO

YES

8. Are you taking any medication that we should be aware of? *

NO

YES

9. Are you pregnant or have you given birth in the last six months? *

NO

YES

10. Is your blood pressure low, medium, or high? *

Low

Medium

High

Please indicate that you have read and understand the following terms and conditions. *

*** If you answered YES to any of the questions above, we advise you to consult a doctor BEFORE you start or increase your physical activity. *** Please advise the Instructor before each class if for any reason your ability to exercise has changed. If you are pregnant, we rely on you to check regularly with your doctor that he/she is happy for you to continue with your classes. It is also wise to wait six weeks after birth before resuming exercise. Pilates exercises, Yoga, and MEDICAL-STRETCHING® are very safe but, as with all forms of physical exercise, if you have any doubts about the suitability of the exercises, you should refer to your medical practitioner. The Instructor can accept no liability for personal injury related to participation in a class if a) Your doctor has advised you against such exercise; b) You fail to observe instructions on safety or technique; or c) Such injury is caused by the negligence of another participant in the class. Please let us know if you are unable to attend your class. Classes cancelled less than 24 hours in advance will be charged to you. Please consult the conditions on our price list.

I have read and understand the terms.