Pilates Instructor's Intake Form and Waiver
Date
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Occupation?
Age?
Weight
Height
What goals do you hope to achieve through the Pilates method?
Have you done Pilates before? If so, where and for how long?
List current or any meaningful previous exercise and activites:
Describe your overall current physical condition:
Do you have any current injuries?
Yes - if yes specify below
No
Has a physician ever restricted your abilities?
Yes - if yes specify below
No
Please check off any health concerns:
Head
Neck
Right Shoulder
Left Shoulder
Right Arm/Hand
Left Arm/Hand
Upper Back
Middle Back
Lower Back
Ribs
Abdomen
Hip/Pelvis
Right Knee
Left Knee
Right Foot
Left Foot
Other
Please describe any injuries or surgeries:
Illnesses and Ailments:
Pregnancies
Other
Scroll through or download the waiver above. Sign below to agree to the terms
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Submit
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