New Client Form

The Pilates Studio

353 Walnut Street Ext

Agawam, MA 01001

Shelly Pirroni

413.222.4035

pioneervalleypilates.com

www.facebook.com/thepilatesstudioagawam
Date of first visit

Month Day Year
Date
Name
Address

Address

Street Address Line 2

City State

Zip Code
Contact Info
Mobile Number
Home Number
Work Number
E mail address
example@example.com
What is the best way to contact you?
Personal Information
DOB
Height
Weight
Occupation
Handedness
Emergency Contact
Emergency Contact Name
Number
Referral Info
Have you done Pilates/ MELT/TRX before?
How did you hear about The Pilates Studio?
How long ago?
Goals and Priorities

What are the main goals that you are hoping to achieve with you program?
1.
2.
3.
What aspect(s) of your health would you like to concentrate on?

Core Flexibility Posture Tone Back/Shoulder Problems Stress Managment Relaxation Other
Lifestyle
What is your stress level?

None Low Moderate High
What is your activity level?

Sedentary Moderate Active Other
What forms of exercise/activities do you do? Please indicate frequency.
General Health History
General Health History: Please leave blank any questions you are not comfortable with. This information is used only to create the best Pilates/MELT program for you)
List in order of most important to least important pain or dysfunction you feel is present in your date of dysfunction body:
1.
2.
3.
Have you seen a general practitioner or specialist for any of these problems? Was there any treatment or diagnosis given? Has the condition changed with treatment?
Was there any treatment or diagnosis given?
Has the condition changed with treatment?
General energy level (scale of 1-10, 10 being optimal) Average hours of sleep per night: Do you have trouble sleeping or insomnia? Do you smoke presently? How long have you smoked? Have you ever smoked? Do you drink coffee? How much per day? Do you drink soda? How much water do you drink per day?
On a scale of 1-10 (1=low, 10=high) what is your energy level?
Do you have trouble sleeping or insomnia?
Do you drink coffee?
Do you drink soda?
How much water do you drink per day?
Have you ever had any surgeries? Include dates and details:
Bone
Tumor
Dental
Cosmetic
Cartilage
Implants
Joint Replacements
Tendon
Organ
Eye
Pacemakers
Stints
Joint replacements
Broken bones
Shunts
Car Accidents
Car Accidents? Date

Month Day Year
Date
Details:
Car Accidents? Date

Month Day Year
Date
Details:
Car Accidents? Date

Month Day Year
Date
Details:
Musculoskeletal System

please include details for any areas
Low Back pain
Mid back pain
Neck pain
Arm Problems
Leg problems
Difficulty walking
Joint pain or dysfunction
Ligament sprains
Muscle strains
Torn muscles
Muscular pain or dysfunction
Arthritis
Cartilage dysfunction or tears
Constant joint stiffness or ache
Other
Nervous System

please include details for any areas
Dizziness or Vertigo
Numbness/tingling
Frequent Headaches or Migraines
Fainting
Frequent Muscle Twitching, ticks or spasms
Loss of coordination
Loss of balance
Nose, Sinuses and Respiratory System

please include details for any areas
Nose Pain
Frequent nose bleeds
Allergies
Difficulty breathing through nose
Hay fever
Frequent sinus infections
Nose surgery
Asthma
Pain on breathing
Chronic/frequent coughing
Frequent shortness of breath
Pain on breathing Frequent shortness of breath

Cardiovascular System and Peripheral Vascular System High blood pressure Heart murmurs
Cardiovascular System and Peripheral Vascular System

please include details for any areas
High blood pressure
Irregular heart beat
Heart murmurs
Varicose veins
Heart palpitations
Frequent Constipation
Frequent diarrhea
Abdominal pain
Colitis, Crohn's Disease, or Ulcers
Frequent Nausea/vomiting
Frequent heartburn
Frequent indigestion or gas
Frequent cramps
Reproductive System

please include details for any areas
Prostate issues or enlargements
Frequent cramping
C section
Heavy flow during period
Currently pregnant (list week)
Menopause or peri menopausal
Cancellation Policy
Please give a minimum of 48 hours notice if you are unable to keep your appointment. Otherwise you will be charged for this time as it has been specifically reserved for you. Sessions cancelled under 48 hours of scheduled time will be charged 50% of session cost, and sessions cancelled under 24 hours notice of scheduled time will be charged full session charge. Duet and trio sessions maintain the same policy. Should one person need to cancel the other participant will have the option of keeping the time slot and having a private session for an additional cost or having a 30 minute private session at no additional cost. For trios the other two participants can have the option of having a duo session for an additional fee or having a 35 minute duo session at no additional cost.
I read, understand and agree to the cancellation policy
Payment Policy
Payment: Due at each session in full, Package discounts are available. We do not take credit cards.
I read, understand and agree to the payment policy
Liability Release Form
Date

Month Day Year
Date
Liability Release Form I agree that The Pilates Studio is in no way responsible for the safekeeping of my personal belongings while I attend class. I release The Pilates Studio from any kind of claim or injury resulting from any act or omission during movement practice or treatment. I understand that classes at The Pilates Studio may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury, property loss or death. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Pilates Studio or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

I understand that I am responsible for payment if I cancel with less than 48 hours notice.
Date

Month Day Year
Date
Type name below to agree to the above conditions
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