Name * First Name Last Name Email * Home Address * Phone number * (###) ### #### Emergency Contact * Relationship * I understand the following information will be used soley for proper fitness level assessment and to create and maintain safe and effective exercise program. * Yes If I have any doubts or concerns about my health or fitness level to safely attend Pilates and/or Personal Training, I agree to first speak with my doctor. * Yes Are you pregnant or have you given birth in the last six months? * Yes No Have you had any of the following clinical tests in the past year? * Bone Density X-Ray MRI Other None Do you have any pain or injuries/conditions that might affect your movement? * Yes No Please list and prior surgeries or deliveries. * Do you carry on your person any emergency medications for allergic reactions or medical conditions? * Yes No Please list any emergency medications you might need. * Describe your work or daily life. * Active Profession Seated at a desk for work a combinations of seated and active What type of things do you enjoy doing? * How often do you exercise? * Never Seldom Often What are your reasons for starting Pilates or Personal Training Sessions? * choose as many as apply Realignment and better posture Increased mobility/flexibility to gain strength follow up to rehabilitation build athletic ability reduce stress other What are your goals with Pilates or Personal Training? * Are you currently experiencing/under a physician's care or recovered from any of the following? * Check all that apply Osteoporosis Osteopenia Osteoarthritis low back pain herniated or bulging disk neck stiffness or pain Scoliosis Stenosis Spondylolisthesis pelvic pain hip Bursitis hip labral tear Avascular Necrosis rib cage pain/issues Hip Snapping Syndrome pelvic floor dysfunction/injury knee pain/issues ankle pain/issues foot pain/issues wrist pain/issues hand pain/issues none of the above Feel free to explain in further detail any of the above checked boxes. Thank you!
