Health Screening Form

Client Name*

First NameLast Name

Birth Date*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Weight*

kg/stone & lbs

Height*

Ft/cm

Please state if you have any injuries/medical conditions that may affect your ability to exercise.*

Please state if you are on any medication.*

Health & Lifestyle*

	Yes	No
Are your currently exercising?
Have you done Pilates, Reformer or Mat before?
Have you any experience weight training?
Are you tracking your daily food intake?
Have you ever experienced dizzy spells when exercising?
Have you had any surgery in the past 12mths
Have you been pregnant in the last 6 months
Do you smoke?

How often do you currently exercise per week? Or how often do you aim to , if new?

What are your goals for training?

Please state if you have any food allergies*

Pilates Event: name/date of event*

Do you consent to photos/videos being used on social media stories and posts for marketing/advertisement purposes

YesNo

I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.

Pilates with Ruth has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I agree to follow all guidelines set out by Pilates with Ruth.
I will follow all adaptions and progressions given when suited to my ability. I release and discharge Pilates with Ruth from any disclosure of my personal information in this Fitness Client Intake Form.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform Pilates with Ruth immediately.

I acknowledge that all payments made are final, non refundable and non trasnferable.Please note Transactions are executed via stripe using their software and data encryption practices.

Please note that online health screening forms are hosted by Jotform using their software and data encryption practices.

Date*

Date

Client Signature*

Health Screening Form

Release and Acknowledgement