Hill View Crescent, Plot No. 5
Client health & consent form
Notice version 2026-09-04
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. The full privacy notice is on the back of this sheet and at /privacy on the studio's website.
1. About you
Full name
Phone
Email
Date of birth
Sex
Female Male Prefer not to say
2. Health screening
Every question needs an answer. A yes only means we 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 — name and phone
3. Your health in your own words
Anything that might change how an exercise is given to you. If in doubt, write it down.
Medical conditions — Heart, blood pressure, asthma, diabetes, osteoporosis, epilepsy…
Injuries and surgeries — Back, knee, shoulder, neck — what, and roughly when
Medication you are taking
Anything that hurts right now
Pregnancy
Not applicable Currently pregnant Postnatal
4. Your practice
Experience with Pilates
New to Pilates Some experience Experienced
What would you like to get out of it?
5. Consent
Each line is a separate decision. Tick what you agree to. 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.
Signature
Date
Name in capitals
If the client is under 18, a parent or guardian signs, as the Data Protection Act, 2019 requires.
Parent or guardian — name, relationship, phone, ID number
Privacy notice
Who holds it
Dhyana Refomer Pilate Studio, at Hill View Crescent, Plot No. 5. Questions, corrections and deletion requests go to bonniehao07@gmail.com.
Why it is collected
Your contact details run your bookings and packages. Your health details let an instructor adapt exercises so a class is safe for your body. Your emergency contact is used only if something happens to you at the studio. Nothing here is collected for any other reason.
Who sees it
Only the instructors who teach you and the staff who handle bookings. It is never sold and never shared for anyone else's marketing. The booking system runs on servers outside Kenya, encrypted in transit and reachable only by the studio’s own staff accounts.
What you can ask for
To see what is held about you, to have anything wrong corrected, to have your record deleted, and to withdraw any consent you gave — including the optional ones. Ask bonniehao07@gmail.com. The studio keeps records for as long as it needs them to teach you and to meet Kenyan tax law, and deletes them after that.
If you are not happy with the answer
Kenya’s Office of the Data Protection Commissioner regulates this, at odpc.go.ke, and you can go to them directly. The studio would rather you raised it here first.