Client Intake Form

Client Intake Form

Dorothy Piper Cronin, NCPT dorothypcronin@gmail.com 971-930-2221

Piper Pilates, 1537 SE Pershing Street & Springwater Pilates, 6210 SE Milwaukie Ave Portland, Oregon 97202

Name

First NameLast Name

Pronouns

Phone number

Email

example@example.com

Address

Occupation

Date of Birth,

Date

How did you hear about us?

Do you have any health conditions, injuries, aches, pains, or limited range of motion? Are they current or past? Please describe.

Please note if you have any of the following health conditions: Stenosis, vertigo, scoliosis, fatigue, osteoporosis, osteopenia, pregnancy, joint problems, eating disorder, seizures or muscle cramps.

Any past surgeries that may impact or limit movement? Please include month and year.

Please list any medications that may impact movement or coordination.

Are you presently doing other kinds of therapy? E.g. massage, physical therapy etc

l

What kinds of exercise or movement do you most enjoy?

What are you intentions (goals) for taking Pilates? What do you want most from your Pilates experience?

Are you vaccinated for Covid-19? Please note any questions or concerns.

What does your typical day involve physically?

Ideally how often would you like to do Pilates? Please note what days and times may work best.

Are you interested in group classes?

Do you find it challenging to stay motivated or consistent in exercise? If so, what may be helpful?

Are you comfortable with tactile (touch) cueing? Please note any requests or concerns.

Is there anything else that you'd like your Pilates instructor to know?

Acknowledgement of Risk and Waiver of Liability

I understand that I will be participating in a fitness program through Piper Pilates that will require physical exertion. Before beginning this program, I was asked by my instructor whether I have any physical limitations, or whether I am taking any medications or receiving any medical treatment that might make it unsafe for me to participate in this fitness program. There is no such limitation, medication, or medical treatment other than those I have written on the attached sheet. I agree to notify my instructor of any changes in physical limitations or health conditions that may impact my participation. I understand that, by signing this statement,I am agreeing to not hold Dorothy Cronin, Piper Pilates or Springwater Movement & Pilates Studio responsible or reliable for any injury that may result either directly or indirectly from my participation in this fitness program.

Date

Participant's Signature

Cancellation Policy

Life gets in the way sometimes. With that in mind, we still require a 24-hour notice for cancellation. If 24-hour notice is not given, I will be charged the full amount for my session. *Client may request to be on a waiting list for a makeup session within the week. Makeup sessions are not guranteed and notification of opening is within 24 hours.

Date

Participant's Signature