Pilates Intake Form

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

How did you hear about these services?

What is your profession by trade?

Chief complaint(s)

Please include a specific body part and severity of symptoms.

Significant past medical history

Please include dates of surgeries, previous injuries, etc.

What physical activities are you currently participating in?

What are your goals of Pilates?

How committed are you to investing in your body's health and wellness?

Have you participated in Pilates before? If yes, when? What was your experience?