New Client Form | Think Silver

Questionnaire

(Your information will remain confidential.)

First name

Family Name

Address

Last name

Birthday

Cellphone

Home Number

Postal Code

Occupation

How did you find out about us?

Work Number

Who referred you?

What would you most like support with right now?

Do you currently exercise or do mindful movement ie. Pilates, Nia, Yoga? Required

Regularly

Occasionallly

Rarely

Not at present

Types of movement you do or have done?

Have you practiced Pilates before? Required

Matwork

Equipment

Both

Have you experienced Nia? Required

Yes

Have you experienced F.U.N. Strength? Required

Yes

MEDICAL, INJURY & HEALTH HISTORY

Please provide details where relevant:

Are you currently taking medication that may affect movement, balance, or energy? Please specify what medication.

Do you experience pain, tenstion or discomfort with movement? Required

Rarely

Sometimes

Often

Sleep quality: Required

Restful

Interrupted

Poor

Do you spend most of your day seated or at a computer? Required

Yes

Do you feel you have sufficient time for recovery between work, life, and movement? Required

Yes

Sometimes

Not really

Pleas read and acknowledge with a tick: Required

Private & Group class sessions are 45min unless otherwise indicated

Appointments must be cancelled at least 17hrs in advance to be honoured

Please inform your instructor before your session of any new injury, illness, pregnancy or change in health.

You are always in control of your movement and may pause, modify, or stop at any time.

Sessions are participatory and rely on open communication

Cellphones need to be switched off unless discussed with your instructor.

Participant agreement, waiver & consent: Required

I, the undersigned participant, acknowledge and agree to the following:

I voluntarily choose to participate in movement, body-based assessment, breath awareness, and private sessions offered by Think Silver studio.

I confirm that, to the best of my knowledge, I am medically fit to participate and have disclosed all relevant health information.

I understand that Think Silver studio does not provide medical diagnosis, or treatment.

I knowingly and freely assume all risks associated with participation.

To the fullest extent permitted by South African law, I waive, release and discharge Think Silver studio, its owners, instructors, staff and representatives from all liability arising from my participation.

I accept responsibility for listening to my body and communicating pain or discomfort immediately.

I acknowledge that my personal information is handled in accordance with POPIA.

I have read, understood and agree to the studio guidelines - that are hanging on the studio wall - and cancellation policy.

Section 2:

What is your occupation? What do you typically do daily?

What are your goals? What do you want most from your time at Think Silver studio?

Do you have any injuries, aches and pains? (recent or old) Please explain.