New Client Registration Form
Client Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Prefer not to say
How did you hear about us?
Have you been referred by someone?
Yes
No
Are you currently experiencing any pain?
*
Yes
No
If yes to the previous question please can you describe as best you can
Are you currently taking any medication?
Yes
No
What is your occupation?
How would you describe you activity levels in the past 2 years (type/frequency/duration)
Have you done pilates before?
Yes
No
Medical Condtions
Please tick if you are experiencing/have experienced any of the below
No medical concerns
Muscle Injury
Spine Injury
Recent Surgery
High Chloresterol
High Blood Pressure
Low Blood Pressure
Rheumatoid Arthritis
Osteoarthritis
Osteopenia
Osteoperosis
Diabetes
Asthma
Epilepsy
Heart Condition
Recent Child Birth
Other (please specify)
Females Only
Are you pregnant or have you been in the past 6 months?
Yes
No
Please accept the below policies
I am not a robot
*
Submit
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