New Client Intake Form

New Client Intake Form
Name*
DOB*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Phone*
Format: (000) 000-0000.
Occupation
Emergency Contact Name*
Emergency Contact Phone Number*

Click YES or NO

Rows	Yes	No
Do You have vertigo
Do you have high blood pressure
Do you have a history of heart problems
Do you suffer asthma?
Do you have osteopenia/osteoporosis?
Do you have blurred vision?
Do you have diabetes? Type I or II?
Have you had a hernia?

Illness/Injury/Cancer?
Chronic pain? Condition?
Any Surgery?
Pregnancy?
Medications?
Current Exercise Routine and Goals
Current activities
What do you want to get out of Pilates?
Comments/Concerns?
How did you hear about Inner Strength Pilates?
This information is true and accurate to the best of my knowledge.
Participant's Signature

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