Pilates Client History
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone number
*
Date of Birth
/
Month
/
Day
Year
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Occupation
*
Exercise/sport/physical activity
*
What is the reason for starting Pilates?
*
Please choose the type of Pilates you would like
*
Please Select
Clinical Pilates to address injury/pain
Pilates in small group and I am injury and pain free
Not sure yet!
Please list current and previous injuries or operations
*
Do any of the following conditions apply?
*
Asthma
Cancer
Cardiac disease
Diabetes
High blood pressure
Low blood pressure
Headaches/migraines
Osteoporosis/osteopenia
Medications
Chronic pain
Pregnancy
Other
None of these above
If yes to any of the above please give details
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
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