Pilates Fitness & Wellness Intake Form

Pilates Fitness & Wellness Intake Form

Complete Intake Form Prior to your Scheduled Appointment
Full name*

First NameLast Name
Address*

Street Address

Post Office Box

CityState

Postal / Zip CodeCountry
Cell Phone Number*

Area CodePhone Number
Home Phone Number*

Area CodePhone Number
E-mail*
Emergency Contact*

First NameLast Name
Emergency Contact Phone number*

Area CodePhone Number
Health & Fitness Intake

Please complete all Intake Questions
Birth Date*

MonthDayYear
Gender - Male/ Female*
Weight*
Height *
Were you referred by a Medical Professional or a client? Do you have an acute injury? Do you need emergency care? How did you hear about us? Please be specific.*
Describe your activities / hobbies and type of employment. Please be specific. Your lifestyle and type of employment play an important role in determining the most beneficial program for you.*
What Pilates Programs or Fitness programs interest you?*
Do you consider yourself to have a sedentary life style?*
Are you interested in weight loss or nutritional programs?*
Have you received a Medical Physical in the past 12 months?*
Have you ever had surgery?*
Is your Doctor currently prescribing drugs or medication for blood pressure or heart conditions? *
Do you Smoke or Vape?*
Do you have any Heart Conditions or High/ Low Blood Pressure?*
Do you feel any chest pain or discomfort with breathing during or after physical activities? *
Has your Medical Doctor recommended limiting physical activities?*
Do you know of any reason why you should limit your physical activities?*
Are you pregnant or postnatal?*
Do you have any joint pain, muscle pain, Arthritis or Osteoporosis ?*
Have you ever had a Hernia?*
Do you have any injuries or disabilities that may limit your activities? *
Do you suffer from motion sickness or inner ear issues?*
Do you lose balance because of dizziness or do you ever lose consciousness? *
Do you have bone or joint problems or pain that could be worsened by change in your physical activities?*
What are your specific long term and short term goals?*
I attest to the accuracy of Pilates Fitness and Wellness Intake Information *

Clear
Balanced Body Studio Policy Agreement /Please Initial Agreement.
Pilates Fitness and Wellness Policies
Pilates Fitness and Wellness Sessions Protocol
Pilates Fitness and Wellness Session Protocol: Please complete the intake form with detailed description of your concerns. A MD is generally recommended, however if you prefer, our Nurse Practitioner can evaluate Intake information and forward any recommendations for program design. When intake information is evaluated, a specialist will schedule an appointment. When you arrive for your appointment, our Pilates Program Instructor will screen you and complete a physical assessment and discuss appropriate treatment. I understand the Policies set forth and authorize treatment and understand risks involved. We follow safety protocols and required all patients to follow those safety guidelines.*
*Please note any concerns or questions regarding Pilates Fitness Programs and/ or Pilates Corrective Movement Treatments. If you have no concerns, please note NONE.
Pilates Fitness and Wellness Session Protocol and Agreement*

Clear
Balanced Body Studio Policy Agreemnet / Please Initial Agreement.
Medical Consent, Safety Protocol and Acknowledgement Waiver
Pilates Fitness & Wellness takes all precautions in ensuring the safety and well-being of the client during Pilates Private Sessions, Massage Therapy, and/or Fitness and Wellness Sessions under NYS Protocol, National Exercise and Sports Trainers Association. We recommend you receive Medical Clearance for your safety.

Medical Consent:

The client states they are fit for Pilates Sessions, Exercise Program/ Massage Therapy Treatments, received medical clearance for Fitness Training and/or Massage Therapy Sessions, and /or understands the risk of injury involved with increasing physical activity and/or receiving treatments without the consent of a physician and has decided to go forward with a Fitness Program and or Massage Therapy Program. The client further understands and consents to assessments, program design, and/ or treatments by the Therapist/ Trainer. The Therapist/ Trainer recommends Medical Clearance by a Physician before starting Therapy and/or Fitness Sessions.

Acknowledgment Waiver :

The client is hereby requesting a Consultation and/or Services with Balanced Body Fitness and Wellness LLC, Pilates Fitness & Wellness, Balanced Body Massages, Myokinesis Therapy, and/or Daniel Thomas for the sole purpose of potentially retaining a Therapist or Personal Fitness Trainer and for no other reason. I acknowledge that I am not an agent or employee of any local, state, or federal government authority; or if I am employed as an agent or employer of any local, state, or federal government authority that I am seeking this consultation in my individual capacity and not the capacity as government agent or employee. If consultation is on behalf of a business entity and not an individual I further represent that I am either a principle, managing agent, partner or if a partner, or if an agent, that I am authorized to execute authorization and wavier on behalf of my principle.

I acknowledge that permission for me to enter the premises or any premises related to the ownership or business of Balanced Body Fitness and Wellness LLC, and/or to receive consultation and/ or services is based on the above acknowledgment, and any misrepresentation made herein to receive the consultation and/or services will be deemed entrapment and Trespassing with Malicious Intent, intentional infliction of emotional distress and all other applicable damages.

I waive any and all defenses I may have against me for entrapment, Trespassing with Malicious intent, Trespassing, Trespassing to Chattel, harassment, fraud in the inducement, intentional infliction of emotional distress, and any other damages incurred by Balanced Body Fitness and Wellness LLC and/or Daniel Thomas as a result of misrepresentation stated above for receiving consultation and/or services rendered to me.

I am aware that signing this document under pretenses is a crime punishable under the laws of New York State.

I have read this document, understand its contents, and sign this waiver of my own will.

Safety Protocol and Waiver:

I read and understood Pilates Fitness and Wellness Safety Protocol and Policies as noted in detail on our Safety Protocol Web Page.

Your safety is our priority and we strongly recommend medical clearance from a Medical Doctor before using our services. If you feel medical clearance is unnecessary and decide to proceed with our services, follow our strict safety protocols. You also understand and acknowledge that though our protocols are designed to minimize exposure, there is a risk of injury.
I agree to Pilates Fitness and Wellness Medical Consent, Safety Protocol, Acknowledgment Waiver and Agreement*

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Cancelation Policy
At Pilates Fitness & Wellness, all appointments are binding. All sessions are prepaid. Rescheduling requests must be received at least 24h before your session in order to avoid being charged. Clients who do not request a rescheduling appointment within 24h notice will be charged 100% of a regular price of of your session.
Cancelation Policy Agreement*

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
NYS PICTURE ID / DRIVERS LICENSE (required to submit with Intake Form)*

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DOWN LOAD NYS PICTURE ID/DRIVERS LICENSE or Send copy of NYS PICTURE ID/ DRIVERS LICENSE via Text to 631.318.4696 Cancelof
Date*

MonthDayYear
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Pilates Fitness & Wellness Intake Form

Health & Fitness Intake

Pilates Fitness and Wellness Policies

Pilates Fitness and Wellness Sessions Protocol

Medical Consent, Safety Protocol and Acknowledgement Waiver

Cancelation Policy