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?

    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: