First Name*

Last Name*

Email*

Telephone Number*

Medical History

Health Questions

Have you had a personal trainer before?

Yes

Are you pregnant?*

Yes

Do you smoke?*

Yes

Any major surgery in the last 10 years?*

Yes

Any minor surgery in the last 2 years?*

Yes

Are you currently taking any prescribed medication?*

Yes

Do you have any allergies?*

Yes

Are you currently seeing a physician/physio?*

Yes

Has your Doctor ever advised you against exercise?*

Yes

If you have answered 'YES' to any of the questions above please give further details here:

Have you ever suffered from the following?

Muscular/joint pain

Yes

Arthritis

Yes

Epilepsy, fainting/dizziness

Yes

High/low blood pressure

Yes

High Cholesterol

Yes

Cardiovascular/heart/chest pain

Yes

Asthma/Respiratory illness

Yes

Diabetes

Yes

Back pain

Yes

Pre/post natal

Yes

If you have answered 'YES' to any of the questions above please give further details here:

Current Physical Ability

Do you have an active lifestyle?

Are you currently involved in regular exercise?

(How often/how long/what kind)

What type of physical activity do you enjoy/not enjoy?

Personal Training Goals. What are your 3 main goals?

This agreement is made between Susan Harker and yourself. Cancellations must be made 24 hours in advance of the scheduled sessions. Sessions cancelled less than 24 hours in advance will be charged in full to the client. Sessions are 55 minutes long. A no show will incur the client being charged the full session price. No refunds will be given. You agree to do Pilates regularly on line or in person regardless of where you are In the world Sessions that can’t be made must be rescheduled.
By clicking submit I declare on this form to the best of my knowledge that the information given is correct and that I know of no reason why I should not participate in an exercise programme. I understand that I enter into any exercise programme entirely at my own risk.

I give permission for Movement For Life to retain my personal information in accordance with the data protection act and understand that I can request my personal details at any time. Movement for Life will not share any personal data with a third party and will hold this data for medical purposes and to make me aware of any offers or information relevant to their services.*

Yes

I have read and understand the Movement For Life terms and conditions.*

Yes

Checkbox Group*

You are aware of the symptoms of COVID-19 and appropriate precautions you can take to keep yourself and those around you safe

Personal Training Registration Form

Health Questions

Have you ever suffered from the following?

Current Physical Ability

Personal Training Goals. What are your 3 main goals?