BLUSH BODIES · NEWTOWNARDS

1-to-1 Pilates Health Form

Before your 1-to-1 Pilates session, please complete this short form so I can plan the session around your recovery, current symptoms and comfort.

Your answers are private and will only be used to support your safe participation at Blush Bodies. Please only include information that is relevant to taking part in your Pilates session.

01

Your details

Fields marked * are required.

02

Emergency contact

Someone I may contact if you become unwell or injured.

03

Your hysterectomy & recovery

Please share only information that is relevant to planning your Pilates session.
This form does not replace medical advice. Because you are returning to exercise after surgery, the session may be adapted or postponed if anything needs to be checked with your GP, consultant or physiotherapist first.
1. How was your hysterectomy performed, if you know? *
2. Has your GP, consultant or physiotherapist advised that you can begin or return to Pilates or general exercise? *
3. Who recommended Pilates to you? *
4. Have you been given any specific restrictions, movements to avoid or limits on lifting or exercise? *
5. Have you had any complications, follow-up treatment or ongoing concerns after your operation that could affect exercise? *

04

How you feel now

This helps me choose a gentle starting point and avoid movements that do not feel right for you.
1. Do you currently have abdominal or pelvic pain, pressure, heaviness, pulling or discomfort with movement? *
2. Are you currently experiencing vaginal bleeding or discharge that your medical team has not told you to expect? *
3. Do you currently notice pelvic-floor symptoms such as leaking, pressure or heaviness, bulging or pelvic-floor pain? *
4. Are your legs still feeling sore or painful? *
5. Where do you mainly feel the leg soreness? *

For example: calf, thigh or whole leg; when it started; whether it is improving; and what makes it better or worse.

6. Do you currently have new or unexplained swelling, warmth, redness or darkening, or throbbing pain in one leg, especially the calf or thigh? *
7. Do you currently have unexplained shortness of breath or chest pain? *
Important: If you have new one-sided leg pain, swelling, warmth or redness/darkening, please seek medical advice before beginning your Pilates session. If this occurs alongside unexplained breathlessness or chest pain, seek urgent medical attention.

05

General exercise screening

Please answer each question honestly.
1. During the last 12 months, have you lost consciousness or lost your balance because of dizziness? *
2. Do you have a heart, circulation or breathing condition that may affect your ability to exercise safely? *
3. Do you have a bone, joint, muscle, back or pelvic-floor problem that could be made worse by exercise? *
4. Are you taking prescribed medication, or managing a medical condition, that could affect exercise, balance, heart rate or blood pressure? *

Please include only information that may affect exercise or any adaptations you may need.

06

Your 1-to-1 session

Tell me what will help you feel comfortable. You can change these preferences at any time.
1. Would you like movements explained and demonstrated before we do them together? *
2. How would you like me to handle hands-on posture corrections? *

For example: a slower pace, more explanation, extra breaks, quiet time to practise a movement or anything you would prefer me to avoid.

For example: rebuilding core strength, moving with less stiffness, confidence with exercise, mobility or general wellbeing.

07

Participation agreement

Please read each statement before confirming.

By submitting this form, you confirm that you have read and agreed to the statements above.