Date of Birth:
How did you hear of KTB Prescribed Pilates?
Do you have any experience of Pilates?
Why have you decided to start Pilates with KTB?
What do you hope to achieve from your Pilates?
Pilates can improve pain caused by repetitive and poor postures. For us to understand what could influence your posture please answer the following:
What is your occupation?
Are you involved in any other activities?
Do you have any hobbies?
Prescribed Pilates is Physiotherapy led. Our Physiotherapists can modify any exercise to help to address any medical issues or pain that you may have. Our Pilates can simply be a form of exercise or as a method of managing a health problem. If you do have an active injury or medical problem then we strongly suggest a 1:1 session to assess this thoroughly. You must declare below any problems that you have had in the past or that you are currently experiencing problems with so that we can make the necessary adjustments within the class.
We need to know if you have any medical history so please complete the following honestly, giving details below where appropriate.
Have you had any of the following:
Heart trouble or a heart defectPain in the chest when you undertake physical activityRegular headachesLose balance because of dizzinessLose consciousness or regularly feel faint or dizzySuffer from either high or low blood pressureHad any major surgery in the last 10 yearsHad any minor surgery in the last two yearsHave asthma, diabetes or epilepsyTaking any regular medicationsBeen pregnant in the past six months, or are pregnant now
Please use the space below to give details of any of the above.
Prescribed Pilates is often used to help manage a joint or muscle problem. Please give details of any of these problems that you may have now or have experienced in the past.
Have you ever been diagnosed with any of the following:
OsteoarthritisRheumatoid arthritisOsteoporosis or OsteopeniaHypermobility Syndrome (excessively flexible joints)Any other bone or joint problemAny other muscular problemAny other condition
Are there any movements that cause you pain?
Consent to Pilates at KTB
• I confirm the information I have given is accurate and hereby give consent to receiving Pilates based physiotherapy from KTB Pilates & Physiotherapy Limited on this and any subsequent occasion.
• I understand that the classes will always be taken by a Chartered State Registered Physiotherapist.
• I understand that it is my responsibility to inform the Physiotherapist taking my class of any change in my medical or health status and also of any pain or discomfort experienced during a class.
• I understand that a 1:1 session is recommended before joining a class to fully discuss and assess any medical, joint or muscular problem that I have disclosed. I understand that my medical history will be treated with the strictest of confidence.
Private Patients Self Funding their Appointments/Pilates:
• I have been advised of the current fees charged by the centre at each clinic and understand the payment terms.
• I agree to leave my payment details so that payment can be taken in advance of each session. Alternatively, I agree to pay at the time of booking each appointment.
Non Attendance Policies
• Over 24 hours notice to cancel - no charge
• Less than 24 hours notice to cancel - £15 fee 30 min appt; £30 60 min appt
• Less than 24 hours notice on more than two occasions - full fee
Prescribed Pilates Classes
• Our Pilates classes are paid for in advance for a six week course. You will reserve a place on a set session and will be expected on that session each week from the date that you pay.
• Allow 24hrs cancellation notice. We do have a flexible policy whereby if you are unable to attend your booked session you can inform reception and change this class to another time within your six weeks according to availability.
I have read and understood the non attendance policy for KTB. Any questions that I raised were answered to my satisfaction by a member of KTBs administration team.