Your Contact Details

Name: ______Date of birth: ______/______/______

Address: ______+______

Telephone (M): ______(H) ______(W) ______

Email: ______

Profession: ______Recommended by: ______

Basic Medical History

Height: ______Weight: ______Do you smoke: ______

Do you suffer, or have ever suffered, from any of the following:

High Blood Pressure: ______Epilepsy: ______Diabetes: ______

Heart problems: ______Headaches: ______Asthma/Breathing problems: ______

Are you taking any Prescribed Medication (if ‘yes’, please give details):

______

Please describe fully if you suffer, or have suffered, from any of the following:

Neck problems:

Joint problems:

Back problems:

Any past major operations: ______

Please list any other physical fitness or sport programmes you are following at the present time: ______

If over the age of 45 years of age:

Have you had a recent medical examination: ______Were the results satisfactory: ______

Have you had a recent bone density scan: ______If ‘yes’, what were the Results: ______

If you have not had a bone density scan, ACH Pilates recommends having one done.

Does your doctor recommend physical exercise: ______

Emergency Contact :

Name:______Contact Tel No:______Relationship:______

Instructor’s Details:

Alexandra HowarthTelephone: 07866 777026Email:

Experience and Aspirations:

Do you have any previous experience of Pilates or Dance? If so, please provide a summary below:

______

What do you hope to gain from your Pilates sessions?

______

Please indicate below where you first heard about ACH Pilates and Dance:

______

Instructors Notes:

  1. Neither the Club nor ACH Pilates will accept liability for any damage or loss to personal property brought onto the Club’s premises.
  2. Neither the Club nor ACH Pilates shall be liable for personal injury while on the Club’s premises, unless it can be proven that it relates to a wilful act, neglect or default of the Club or ACH Pilates.
  3. Please be considerate to all other class attendees and club users at all times.
  4. Please ensure the appropriate footwear is worn at all times.
  5. Please come to the sessions at least 5 minutes before the scheduled start time
  6. It is the responsibility of each client to ensure that they are capable of using any equipment and that they do so at their own risk.
  7. Classes cancelled without 24 hours notice will be charged at the full rate.

Please tick here [ ] to confirm that you give permission for ACH to contact you for marketing purposes and for special offers.

Signature: ______Date: ____/____/_____

ACH Pilates and DanceTelephone: 07866 777026Email: