New Client Intake Form
Please fill this out to the best of your ability. If you have any questions, please let us know. Thank you!
Name
*
First Name
Last Name
Date of Birth
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What services are you interested in?
*
Please Select
Pilates
Strength Training
Pilates & Strength Training
Online Strength Training
Online Nutrition Coaching
Online Training & Nutrition Coaching
*if you select an option that included nutrition, a separate form will be provided to fill out after the completion of this form*
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 with Pilates?
*
Please Select
Low
Moderate
Hight
What is your experience with Strength Training?
*
Please Select
Low
Moderate
Hight
What is your experience with cardiovascular/endurance training?
*
Please Select
Low
Moderate
Hight
What is your experience with stretching/mobility work?
*
Please Select
Low
Moderate
Hight
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 you marked "yes" to any of the questions above, please describe in more detail below (diagnosis, limitations needed, symptoms, etc.)
*
Do you have arthritis?
*
Yes
No
Do you have osteopenia or osteoperosis?
*
Yes
No
When was your last bone density exam? (if applicable):
*
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 any pain?
*
Yes
No
If marked yes, please describe in more detail.
*
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/ADHD?
*
Yes
No
Do you have hearing limitations?
*
Yes
No
Do you have vision limitations?
*
Yes
No
Are you currently under a physicians care?
*
Yes
No
Do you take any medications?
*
Yes
No
If you take medications, please list below (all that you feel comfortable disclosing)
*
What are some of your favorite movements, hobbies, or activities?
*
Do you have any questions for us before we begin working together?
*
Submit
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