Name

First Name

Last Name

Do you have any past or present injuries, surgeries or health concerns? Describe them including dates.

Are you currently under medical care? If so, have you received a medical release to participate in Pilates? Include any medications.

Are you pregnant or post natal(less than 12 months)? Due/Due Delivery Date?

Have you been tested for Osteoporosis(Bone Density)? Results?

Are there any other issues, concerns or information you would like us to know?

Do you participate in physical activity? If so, what type and how often?

Do you have any past training in Pilates? If yes, where and how long?

What does your typical day involve physically? (sitting, standing, lifting)

What are your goals? What do you want most from this program?

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