Intake FormPlease complete the form below at least 36 hours prior to your scheduled session. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of Birth * MM DD YYYY Have you done Pilates before? * Yes No Previous Pilates experience (if any) Fitness and health goals you wish to achieve through Pilates * Physical activities you are involved in currently, previously and as a child * Describe your current physical condition, strengths, weaknesses, and flexibility * Areas of pain, injury, restricted movement, or surgery Lower Back Upper Back Mid Back Hip / Pelvis Ankle / Foot Knee Leg Head Neck Ribs Abdomen Shoulder Arm / Hand C-section Other ...Further details, if any. Indicate right or left where applicable Do you suffer from any of the following: Chest Pain Heart Conditions High Blood Pressure Low Blood Pressure Dizzy Spells Glaucoma Asthma Diabetes Epilepsy Arthritis Osteoporosis Bone / Joint Problems Other ...Further details, of any Are you taking any drugs or medications which may affect your ability to exercise * Yes No Details on any medical questions above, or any health concerns not already mentioned Life stresses and, or occupational based stresses/repetitive actions that affect your health Do you have any allergies, diet restrictions or special diets you adhere to What is your height * Are you right or left handed? What size are your feet? (for the purposes of fitting for Pilates socks) For female clients... Are you pregnant or have you given birth recently Emergency Contact Name, Relationship, and Phone Number * How did you hear about us? Search Engine (Google, Bing, etc.) Referral (word-of-mouth, other Pilates instructors, etc.) Social Media Platform (LinkedIn, Facebook, etc.) Other Please read below Terms of Service, Important Information, Waiver, and Release Terms I have read and agree to the terms and policies listed above * Yes Which package do you wish to purchase/days you wish to attend? * Please use this section for any additional information you wish to share. We will respond ASAP via text. If you prefer to be contacted in another manner, please state below Join mailing list for promotional information and updates? Yes No Thank you! Your registration form is now complete.
