Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Classes not attended or late cancelled are subject to full-payment and are non-refundable. Do you consent to receiving class email reminders?  *

Yes

No

Do you consent to receiving marketing information from OsteoPilates Cornwall? *

Yes

No

Health Questionnaire

(tick those that apply)

Low Back and/or Pelvic Pain

Joint Pain

Spinal Conditions e.g. Ankylosis Spondylitis / Osteoarthritis)

Osteopenia/Osteoporosis

Joint Conditions e.g. Rheumatoid Arthritis / Osteoarthritis

Hypermobility (e.g. Benign Joint Hypermobility or Ehler’s Danlos)

Heart and/or Circulation Conditions

High or Low Blood Pressure

Epilepsy

Allergies (requiring Epi-Pen use)

Diabetes

Cancer (current or past)

Pregnant or less than 12 months post-partum)

Uterine/Bladder/Vaginal/Rectal Prolapse

Respiratory Conditions (e.g. Asthma, COPD)

Hearing or Sight Issues

Recent physical trauma or injury within the last 12 months (e.g. stroke / ligament injury / fractures / road traffic collisions)

Recent surgery within the last 12 months

Relevant past injuries longer than 12 months ago

Relevant past surgeries longer than 12 months ago

Health Declaration: *

Whilst every care is taken to minimise the risks associated with undertaking exercising, it is impossible to predict your body’s reaction to a given exercise. It is important that you realise that you may stop exercising when you wish because of fatigue or discomfort. By submitting this form, you confirm that you have completed the health questionnaire to the best of your knowledge, and you have provided accurate and full information regarding your health status. Should any changes to your health occur, it is your responsibility to notify your instructor. You confirm that you are aware that if you choose to disregard any given advice, you do so voluntarily and accept liability for any resulting injury. Please tick here to confirm you agree to the above statement

Yes