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Pilates Health & Consent Screening Form

First name*

Last name*

Email*

Phone*

Address*

Birthday*

Day

Month

Year

Biological Sex*

Female

Male

This streamlines the form, allowing us ask relevant health and safety questions where appropriate (e.g. pregnancy).

Occupation

We ask about occupation to identify postural demands, load exposure, and repetitive movement patterns that may influence symptoms, injury risk, or exercise selection.

Emergency Contact Name*

Relationship To You *

Emergency Contact Phone Number*

Harris Mind & Body (HMB) services that interest you. Please tick all options that apply.*

Physiotherapy

PelviPower

Pelvi Saddle

FootScan

Orthotics

Nutrition

Pilates Mat Group Classes (max 6 people)

Pilates Reformer Group Classes (max 4 people)

Pilates Clinical Group Classes (max 4 people)

Private Pilates Session (60 mins)

Private Pilates Session (30 mins)

Women's Health Specialist

HMB Online Shop (Pilates socks, small pieces of equipment, etc)

Other

How did you hear about us? Please tick all options that apply.*

Google / other search engine

Website

Google Maps

Facebook

Instagram

TikTok

Word of mouth

Friend

Family member

Walked past / local area

Recommendation from a healthcare professional

Other

***

This next section looks at your Physical Activity Readiness (PAR-Q)

This helps us understand whether there are any health considerations we should be aware of so we can support you safely and appropriately in your sessions.

If you answer YES to any of the questions in this section, we recommend that you speak with your GP or healthcare professional before starting a new physical activity.

This doesn’t necessarily mean you can’t join one of our Pilates sessions — it simply helps us ensure your sessions are safe and appropriate for you.

If you have already spoken with your GP or healthcare professional and have been advised that you are safe to proceed, please note this in the “tell us more” section linked to the relevant question(s).

Has your doctor ever told you that you have a heart condition and that you should only do physical activity recommended by a doctor?*

yes

Do you experience chest pain during physical activity?*

Yes

In the past month, have you had chest pain when not doing physical activity?*

Yes

Do you ever lose balance because of dizziness or have you ever lost consciousness?*

Yes

Do you have a bone, joint, or muscular condition that could be made worse by changes in physical activity?*

Yes

Is your doctor currently prescribing medication for blood pressure or a heart condition?*

Yes

Do you know of any other reason why you should not take part in physical activity?*

Yes

***

Relevant Medical History

Please tick any that you feel are relevant to your care.

Cardiovascular

Hypertension (high blood pressure)

Hypotension (low blood pressure)

Angina

Heart condition (e.g. arrhythmia, heart disease)

Respiratory

Asthma

Chronic Obstructive Pulmonary Disease (COPD) or other chronic lung condition

Neurological

Stroke / TIA

Epilepsy

Parkinson’s disease

Multiple sclerosis

Other Neurological Condition

Metabolic / Endocrine

Type 1 diabetes

Type 2 diabetes

Weight management considerations

Musculoskeletal

Osteoarthritis

Rheumatoid arthritis or inflammatory arthritis

Osteopenia

Osteoporosis

Acute back pain (recent onset or flare-up)

Chronic back pain (ongoing or recurrent)

Surgical History

Hip replacement

Knee replacement

Spinal / back surgery

Shoulder surgery

Ankle surgery

Other Surgery

Yes

Mental Health

Anxiety

Depression

Other

Other medical condition(s) or additional notes you would like to share?

Medical history confirmation*

I confirm that I have reviewed the medical history list above and have ticked all conditions that are relevant to me.

None apply to me

***

Movement, Participation & Goals

The following questions help us understand where you are now and how best to support you in classes or clinical sessions.

How do you see yourself right now?

Perception of your current fitness (out of 10)*

1/10

2/10

3/10

4/10

5/10

6/10

7/10

8/10

9/10

10/10

Motivation towards your fitness (out of 10)*

1/10

2/10

3/10

4/10

5/10

6/10

7/10

8/10

9/10

10/10

What support do you need to participate safely?*

I have a hearing impairment

I have a visual impairment

I have difficulty getting down to the floor

I have difficulty weight bearing

I find balancing a challenge and would benefit from additional support

None of these apply to me — I am able to do most things

Anything else you would like us to know to help you be more comfortable?

What movement are you familiar with? Movement or exercise you enjoy, or have taken part in within the last year (tick all that apply):

Pilates Mat

Pilates Reformer

Pilates Clinical

Pilates Private Sessions

Tai Chi

Yoga

Gym - Weights

Gym - Cardio

Group Exercise Classes

Running

Walking

Swimming

Cycling

Dance

Netball

Football

Hockey

Rugby

Badminton

Tennis

Horse Riding

Sport-specific training

None

Other

What are your health, well-being, and/or fitness goals?*

***

Consent for Pilates & Clinical Exercise at Harris Mind & Body

This consent form is designed to help you understand what Pilates sessions at Harris Mind & Body may involve and to confirm your agreement to take part.

Please read the statements below and select each box to confirm your consent.

I understand that Pilates sessions at Harris Mind & Body may include mat-based exercises, the use of small props, and where appropriate, Pilates equipment such as the reformer and other studio apparatus.

I understand that Pilates involves physical movement and exercise, and that, as with all physical activity, there is a small risk of discomfort, muscle soreness, or injury.

I understand that sessions are taught by qualified teachers and physiotherapists, and that exercises will be adapted where appropriate to support safe participation.

I understand that I am responsible for informing my teacher or physiotherapist of any changes to my health, symptoms, or comfort levels.

I understand that I may stop or modify any exercise at any time if I feel pain, dizziness, excessive fatigue, or discomfort.

I understand that my participation in Pilates sessions is voluntary.

I confirm that the information I have provided is accurate to the best of my knowledge.

Consent*

Yes — I have read and understood the information above and consent to participate in Pilates sessions at Harris Mind & Body.

***

Pilates Classes – Terms & Conditions

These terms are in place to help our studio run smoothly and to ensure fairness for all clients attending our small-group classes.

Please tick each box to confirm that you have read and understood each point.

Purchases & Validity

All Pilates class purchases are final and non-refundable.

Pilates group class credits are valid for 3 months from the date of purchase (or from a selected start date, where applicable).

Credits cannot be extended beyond this period.

Booking Options

You may purchase single sessions or blocks of 5 or 10 classes.

Please only purchase what you realistically expect to use within your 3-month validity window, as unused credits cannot be refunded or carried forward.

Cancellations

If you cancel a class with more than 24 hours’ notice, the credit will automatically be returned to your account for you to use another time within your valid period.

If you cancel a class with less than 24 hours’ notice, the class credit will be used and cannot be returned. This policy helps us manage small class numbers and support our teaching team.

Class Numbers & Cancellations By Us

Our group classes are intentionally kept small to provide the best possible experience and level of support.

In the rare event that only one person is booked into a group class, the class may be cancelled by the teacher.

If this happens, your class credit will be returned to your account, and we will do our best to give you as much notice as possible.

Studio Etiquette

We are a socks-only studio. All clients are required to wear socks for all classes. Grip socks are recommended for safety and comfort and are available to purchase at reception from as little as £5 per pair.

Mobile phones - please place your phone on silent during classes to support a calm and uninterrupted experience for everyone.

Health Updates & This Screening Form

I understand that it is my responsibility to keep my teacher and/or physiotherapist informed of any changes to my health, symptoms, or circumstances that may affect my participation in sessions.

I understand that I am expected to update my screening form at least annually, or sooner if there are any changes to my health, medications, or personal details.

By booking and attending classes at Harris Mind & Body (HMB), you agree to these terms and conditions.

I agree*

Yes

Thank you for your understanding — these policies help us offer high-quality, personalised Pilates in a supportive studio environment.

Are you over 18?*

Yes

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Your Signature*

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Today's Date*

Thank you for your understanding — these policies help us offer high-quality, personalised Pilates in a supportive studio environment.