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First name
*
Last name
*
Birthday
*
Month
Day
Year
Address
Email
*
Phone
Emergency contact
Name
*
Relationship
*
Number
*
Health History (please check any that apply)
Back Trouble
Neck Trouble
Shoulder Problems
Hip Problems
Knee Problems
Other Joint Problems (wrists, ankles, elbows)
Arthritis
Hypertension (high blood pressure)
Hypotension (low blood pressure)
Glaucoma
Diabetes or low blood sugar issues
Asthma
Epilepsy
Osteoporosis / Osteopenia
Pregnant (currently)
Any surgeries in the last 2 years?
*
Yes
No
Any other medical concerns?
*
Yes
No
If yes explain
Exercise & Lifestyle Background
Does your work/sport involve any of the following?
*
Sitting for long periods of time
Standing for long periods of time
Lifting heavy weights
Other repetitive actions:
Explain
Is this your first time doing Pilates?
Yes
No
If no, where have you practiced before?
Home with video/DVD
Other studio – Mat class
Other studio – Equipment
Other
Other:
Have you been pregnant in the last 6 months?
Yes
No
Have you had children?
Yes
No
If yes, was delivery by cesarean?
Yes
No
Do you experience dizziness or balance loss when exercising, standing up, or changing positions?
Yes
No
Are there specific movements that cause you pain?
Yes
No
If yes, please describe:
Referrals & Goals
Have you been referred to Pilates by a medical professional?
Yes
No
If yes, may we contact them?
Yes
No
Name/number
What are your main reasons for starting Pilates?
Short-term goals (next 3–6 months):
Long-term goals (6 months+):
How much time are you willing to invest to achieve these goals?
Date
*
Month
Day
Year
Signature
*
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