Pilates Client Intake Form

Pilates Client Form

Information & Medical Form
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

TownState

Post Code
Emergency Contact Name

First NameLast Name
Emergency Contact Number

Area CodePhone Number
Hobbies/Physical Activities:
Please check the conditions that apply to you*

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyBroken BonesSpinal ConcernsMusculoskeletal Discomfort
What fitness and health goals do you wish to achieve through Pilates*

Increase flexiblityIncrease strengthIncrease lung capacityToningRelaxationAlignment & posture correctionPain reliefBalance
Are you currently taking any medication?*

YesNo
Signature

Clear
"You are only as young as your spine is flexible"

Joseph Pilates
Should be Empty:

Pilates Client Form