Intake Form
Full Name*
First
Last
Date of Birth (mm/dd/yyyy)*
-
Month
-
Day
Year
Date
Occupation
Height*
Weight*
Do you have any Pilates experience? If so, please explain.
Please Check All That Apply (current and/or past conditions)*
Asthma
Neck Pain
Back Pain (low)
Back Pain (mid)
Arthritis
Hip Condition/Replacement
Osteopenia/Osteoporosis
Neurological Disorders
Spine Disorders
Heart Disorder
High Blood Pressure
Headaches
Dizzyness/Vertigo
Abdominal/Bowel Disorders
Hearing Issues
Cancer/Tumors
Other Current and/or Past Conditions (please explain)
Please elaborate on any of the conditions you checked in the previous section:
Please list all injuries and surgeries, or pregnancies including year/due date
Please describe any other condition that might limit your participation
Do you adhere to a consistent diet?
Do you exercise regularly? If so, how often? What type?
What are your health and fitness goals?
Is there anything else you wish to let us know that will better help us work with you?
I hereby grant Hallee Altman Pilates the right to take and use my Photo for any lawful purpose such as; social media, marketing, and website content.
YES
NO
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