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Kati Lunt Pilates

Health screening form

This form must be completed prior to your session.

Your information is private and stored securely.
1

About you

Fields marked “Required” must be completed.

A completed copy of this form will be emailed to this address.

2

Health screening

Please answer Yes or No to every question.

1Has your doctor ever told you that you have a heart condition or should only undertake physical activity under medical supervision?
2Do you experience chest pain during physical activity?
3Have you experienced chest pain whilst at rest within the last month?
4Do you lose balance because of dizziness or have you ever lost consciousness?
5Do you have a bone, joint, muscle, tendon or ligament condition that could be made worse by exercise?
6Have you been diagnosed with a heart condition or high blood pressure or any other cardiovascular condition?
7Are you pregnant or have you given birth within the last six months?
8Have you had surgery, serious illness or injury within the last 12 months?
9Do you have any medical condition that may affect your ability to exercise safely?
10Do you currently have, or have you previously suffered from, any back problems or conditions?
11Are you currently taking any prescribed or regular medication?
3

Health concerns and goals

This helps your instructor prepare for you.

What would you like to achieve through Pilates?
How did you hear about us?
4

Please read this carefully before signing.

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I will tell my instructor about any changes to my health before each class.

I understand that Pilates involves physical activity and participation carries an inherent risk of injury. I agree to exercise within my own limits and stop immediately if I experience pain, dizziness, breathlessness or feel unwell.

If I have health concerns or answered Yes to a screening question, I understand that I should seek advice from my GP or healthcare professional before participating. I voluntarily participate at my own risk.

Nothing in this agreement excludes or limits liability for death or personal injury caused by negligence, or any other liability that cannot legally be excluded under UK law.

How we use your information

Your information is collected to support your safe participation and business administration. It is stored securely, kept confidential, and processed in accordance with UK GDPR and the Data Protection Act 2018. It will not be shared unless you consent or the law requires it.

Use your finger or a stylus to sign inside the box.

Your form is sent securely. Please tap the button only once.