Jiva Health client enrolment form Question Title * 1. Name Name * Occupation * Address Address 2 City/Town Post Code * Email Address * Phone Number * Question Title * 2. What days/times are convenient for you? If there are specific times such as before or after work please let us know in the comment box Monday am Monday pm Tuesday am Tuesday pm Wednesday am Wednesday pm Thursday am Thursday pm Friday am Friday pm Saturday am Saturday pm Sunday am Sunday pm Comments (please specify times) Question Title * 3. What is your daily lifestyle of movement i.e. are you working at a desk? Are you working from home attempting to be comfortable? Are you a mum? Please let us know anything that maybe relevant to your movement. Question Title * 4. What are you looking to achieve from starting a yoga or Pilates practice? Question Title * 5. Have you practiced yoga or Pilates before? No Yes, a little Yes, a lot Yes, but a long time ago Question Title * 6. If you wish to start Pilates do you know if you would like mat or reformer Pilates? Mat Pilates Reformer Pilates unsure, will take guidance Question Title * 7. Do you have any injuries or particular tension? Question Title * 8. Do you have a timeline that you are looking to be in great shape for, such as a summer coming up or a wedding, or a sports activity? Question Title * 9. Please let us know if you suffer with any of the following conditions that may affect how you move Heart defect or heart trouble chest pain during exercise high blood pressure low blood pressure feelings of dizziness or feeling faint when you exercise frequent headaches asthma diabetes arthritis osteoporosis osteopenia bone or joint problems I am taking medication that may affect my ability to move (please add details below) Other (please specify) or details Question Title * 10. For women only: are you pregnant? Yes (please give details of how many weeks and any pregnancy related issues you may have) No Pregnancy details Question Title * 11. Have you been through anything that may have had an impact on your pelvic floor/core health? Such as pregnancy, a hernia, c-section, abdominal surgery, abdominal muscle separations Question Title * 12. Following your private session do you know if you would like to attend group classes or further private sessions? group mat classes private sessions semi-private sessions unsure, will follow recommendations Question Title * 13. Your safety and welfare are of paramount importance to Jiva Health. Jiva Health and the teacher will do all that is reasonably possible to ensure your safety in class and the safety of your personal belongings. In stating my name/signing I agree to inform the teacher or therapist of any injury that may affect my participation in class and understand that exercises may involve hands-on corrections and am happy for the teacher to work in this way. I understand that classes at times may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury. I agree that Jiva Health is ultimately not responsible for injury or my personal belongings while I attend a class. If you agree please state your name Done
