Intake Form | Restore Pilates Chicago

Pilates Intake

First Name

Last Name

Phone

Have you practiced Pilates on a mat or equipment? If yes, please describe your experience.

Thanks for submitting!

Height

Sleeping Position

RIght or Left Hand Dominant?

Please list all physical activities you participate in regularly:

Please list any physical limitations or chronic illiness(es) that may prevent you from some exercises (e.g. uncontrolled high blood pressure, etc)

Please list any accidents, injuries or surgeries you have had with dates:

Please list any prescription and over-the-counter medications you are taking, if any:

Please list any confirmed medical diagnosis you have from a licensed physician:

Please inform your instructor if you experience any feelings of pain or discomfort at any time during your session. Your safety and personal comfort are important to us.

Birthdate

What are your pronouns?

Our instructors may want to adjust your alignment during a class. Are you comfortable with hands-on adjustments?

Yes

What are your long term/short term goals?

Is there anything else you’d like us to know?