Essential Information For Each Client:
Full Name: (required)
Your Email (required)
Cell Phone Number: (required)
Contact in case of an emergency (name & phone):
Emergency Contact Name: (required)
Emergency Contact Phone: (required)
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?
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: