Intake Form

Essential Information For Each Client:

Contact in case of an emergency (name & phone):

Dear Clients: Please write out what your goal is for your Pilates session?

For Online Only: What kinds of Pilates props would you like to use?
BallRollerRingChairArcBlocksBands

Do you have osteoporosis? YESNO

Do you have osteopenia? YESNO

If you currently have osteoporosis, do you have a history of bone breakage? YESNO

Have you ever had cardiovascular disease (heart problems)? YESNO

Have you ever had pain or pressure in the left mid chest area? YESNO

Do you have spells of dizziness? YESNO

Do you experience extreme breathlessness after exercise? YESNO

Do you have high blood pressure? YESNO

Do you currently smoke? YESNO

Do you have diabetes? YESNO

Are you taking medications that might cause adverse effects if combined with exercise?

Please list any other medical conditions that require special consideration?

Do you have any physical injuries or limitations that could be exacerbated by exercise?
If ‘Yes’ please explain: