New Client Intake Form

New Client Intake Form
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
What service are you interested in? *
What are your primary goals in working with us? *
Please describe some short term goals you'd like to set for yourself (within the next few months to a year) *
Please describe some long-term goals that you'd like to set for yourself (within the next few years) *
What is your experience level with Pilates? *
What is your experience level with strength training? *
What is your experience level with cardiovascular/endurance training? *
What is your experience level with stretching/mobility work? *
Please describe your experience with any/all of the modalities listed above (type of training, years of experience, whether you enjoyed it, etc.) *
Are you currently exercising? *

Yes No
If you are currently exercising, please describe what you are currently doing, where you are training, and how often you are exercising per week. *
Do you smoke? *

Yes No
Do you have a heart condition? *

Yes No
Do you have a lung condition? *

Yes No
Do you have back pain? *

Yes No
Do you have high blood pressure? *

Yes No
If answered "yes" to any of the questions above, please describe below. *
Do you have arthritis? *

yes no
Osteopenia/osteoperosis? *

yes no
Have you had/when was your last bone density scan? *
Do you have a physician's permission/are you cleared to participate in an exercise program? *

yes no
Do you have any current injuries? *

Yes No
Do you have current pain? *

yes no
Please describe any other pre-existing conditions, health issues, pain, past/present injuries, conditions, or surgeries if they were not indicated above. *
Do you have ADD or ADHD? *

yes no
Do you have hearing limitations? *

yes no
Do you have vision limitations? *

yes no
Are you currently under a physician's care? *

yes no
Do you take any medications? *

yes no
If you take medications, please list below (all that you feel comfortable disclosing) *
Do you have any questions for us before we begin working together? *
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