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Pilates Intake
First Name
Last Name
Email
Phone
Have you practiced Pilates on a mat or equipment? If yes, please describe your experience.
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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
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