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Group class registration form

Registration and simple health questions for Pilates, strength or falls-prevention classes, flagging anything to check first.

How to use it: Group Classes for Physiotherapists: One Hour, Many Patients

The class

  1. Which class Short answer · required
  2. What you would like to get from the class Written answer

Your health

  1. A GP has told me I have a heart condition or high blood pressure Tick box · a yes is flagged to the physio
  2. I get chest pain, dizziness or breathlessness with activity Tick box · a yes is flagged to the physio
  3. I am pregnant or have given birth in the last 6 months Tick box · a yes is flagged to the physio
  4. I have had surgery or an injury in the last 3 months Tick box · a yes is flagged to the physio
  5. Anything else the instructor should know Written answer
  6. Taking part To read and agree to · required I will tell the instructor before class if my health changes, and stop and tell them if I feel unwell during the class.

Signature

  1. Your full name Short answer · required
  2. Date Date · required

Signature

The patient signs on screen, on their phone or at the front desk, and the signed copy is kept on their file.

A starting point, not clinical advice. Check that it fits your patients, your practice and the rules where you work before you use it.