Postnatal Medical Form | Shine Dance and Pilates

Postnatal Pilates Medical Disclaimer Form

Client's name

Client's Date of Birth

Baby's Name

Baby's Date of Birth

Phone

Birth & Recovery

Type of Birth

Vaginal birth

Assisted vaginal birth

Caesarean birth

Were there any complications during pregnancy, labour, or birth?

Yes

If Yes, Please explain:

Have you attended your postnatal check?

Yes

Unsure

Have you been advised that you can return to physical activity?

Yes

Unsure

Current Symptons

Please provide any additional information:

Abdominal & Pelvic Floor

Have you noticed a separation or bulging along the abdominal midline?

Yes

Unsure

Have you previously seen a pelvic-health physiotherapist?

Yes

If yes, please provide any relevant recommendations or restrictions:

4.⁠ ⁠Medical Information

Are you currently under the care of a doctor, midwife, physiotherapist, or other healthcare professional for a postnatal condition?

Yes

If yes, please provide details:

Are you currently taking any medication that may affect your ability to exercise?

Yes

If Yes, please specify

5.⁠ ⁠Exercise History & Goals

Before pregnancy, what type of exercise did you regularly do?

What exercise have you done since giving birth?

Other:

6.⁠ ⁠Medical Disclaimer, Responsibility & Consent

I understand that postnatal recovery is individual and that Pilates exercises should be progressed gradually according to my recovery and individual circumstances.

I confirm that the information I have provided is accurate and complete to the best of my knowledge.

I understand that I should inform the Pilates instructor about any new, unusual, or worsening symptoms during or after exercise.

I understand that Pilates instruction is not a substitute for medical advice, diagnosis, or treatment. If I have any concerns about my recovery or ability to exercise, I will seek appropriate advice from a qualified healthcare professional.

I understand that participation in the class is voluntary and that I am responsible for following the instructor’s instructions and taking reasonable care of myself and my baby throughout the session.

I understand that, to the extent permitted by law, the instructor/business will not be responsible for injury, illness, loss, or damage arising from my participation or my baby’s presence in the class, except where liability cannot legally be excluded or limited.

I understand that I should stop exercising and seek appropriate medical advice if I experience pain, bleeding, dizziness, unusual breathlessness, or any other concerning symptoms.

Client Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Day

Month

Year

This form is intended as a general screening and disclaimer document and does not replace individual medical assessment or professional healthcare advice.

Joseph Pilates

“Every moment of our life can be the beginning of great things."

Dance for mind and body

“A 2003 study in the New England Journal of Medicine by researchers at the Albert Einstein College of Medicine discovered that dance can decidedly improve brain health."

Martha Graham

“Nobody cares if you can't dance well. Just get up and dance."