New client

Before your first session

A few minutes now means your instructor knows how to work with your body from the first minute.

This form asks about your health so your instructor can teach you safely. That is the only thing it is used for. You can ask to see, correct or delete what is held about you at any time.

Read the full privacy notice

1 About you

Full name

Phone

Email optional

Date of birth optional

2 In case of emergency

Someone the studio can call if something happens to you here. Used for nothing else.

Contact name

Contact phone

3 If the client is under 18

A parent or guardian signs, as the Data Protection Act requires. Leave blank if this is not you.

Parent or guardian name optional

Relationship to the client optional

Parent or guardian phone optional

National ID number optional

4 Health screening

Six questions, and every one needs an answer. A yes is not a refusal — it only means the studio will ask for a note from your doctor before your first class.

Has a doctor ever said you have a heart condition, or that you should only do physical activity recommended by a doctor? Yes No

Do you get chest pain when you are physically active, or while at rest? Yes No

Do you lose your balance because of dizziness, or have you ever lost consciousness? Yes No

Do you have a bone or joint problem that could be made worse by exercise? Yes No

Are you taking medication for blood pressure or a heart condition? Yes No

Is there any other reason you should not do physical activity? Yes No

Your doctor’s name optional

Your doctor’s phone optional

5 Your health in your own words

Tell us anything that might change how an exercise is given to you. If in doubt, write it down.

Medical conditions optional

Injuries, current or past optional

Surgeries optional

Medication you are taking optional

Anywhere that hurts right now optional

Pregnancy

6 Your practice

Experience with Pilates

How active are you at the moment?

What would you like to get out of it? optional

How did you hear about us? optional

Anything else we should know optional

7 Consent

Each one is a separate decision. The last two are optional and declining them changes nothing about your booking.

Everything I have written above is accurate and complete. I understand that Pilates is physical exercise carrying inherent risk of injury, that I take part voluntarily, and that I will stop and tell my instructor immediately if something hurts or if my health changes. I accept Dhyana Refomer's booking and cancellation policy. I agree that Dhyana Refomer Pilate Studio may hold the health information on this form, and use it only to teach me safely. I understand it is stored on servers outside Kenya, and that I can ask to see it, correct it or have it deleted at any time. Dhyana Refomer may send me occasional news about classes and offers. I can unsubscribe at any time, and saying no here changes nothing about my booking. Optional. Dhyana Refomer may use photographs or video of me taken in class on its website and social media. Saying no here changes nothing about my booking. Optional.

Type your full name to sign

Privacy notice version 2026-09-04. A copy of what you signed is yours to download on the next screen.

Prefer paper? Print the blank form and bring it with you.

Hill View Crescent, Plot No. 5

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