Client Intake Form - SpaceCraft


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City  Pilates   Client  Intake  and  Medical  History  Form       Your  information  will  never  be  shared  or  used  for  any  purpose  other  than  programming   or  to  contact  you  regarding  your  training.    

Client  Information  

  Name  __________________________________   Date  ______________     Preferred  Phone  _________________________   E-­‐mail  __________________________________   Address_________________________________________________________________   Date  of  Birth_____________________________   Occupation  _____________________________________________________________     How  did  you  hear  about  City  Pilates?  Who  referred  you?   _______________________________________________________________________    

Emergency  Contact  

  Name  __________________________________________   Relationship_____________________________________   Phone  __________________________________________      

Medical  History     Do  you  have  any  injuries,  aches,  pains,  or  health  conditions?  Are  they  current  or  past?   ________________________________________________________________________ ________________________________________________________________________     Past  Surgeries?    Please  describe,  including  dates     ________________________________________________________________________     Are  you  pregnant?    If  yes,  how  far  along?    _____________________________________     Current  Medications    ______________________________________________________     Current  or  past  smoker?    If  yes,  number  or  packs  per  day?    ________________________        

 

Please  check  any  that  may  apply:       ____Allergies:    If  yes,  please  list    ____________________________________________   ____Arthritis:    Type?    _____________________________________________________   ____Asthma:    Do  you  carry  an  inhaler  with  you?    _______________________________   ____Back  Pain:    If  yes,  please  describe    _______________________________________   ____Cancer:    Type?    _______________________________________________________                    Active  or  Remission?    How  long?    ________________________________________   ____Chronic  Fatigue  Syndrome     ____Cystic  Fibrosis   ____Diabetes:    Type  1  or  Type  2?    ____________________________________________     ____Emphysema   ____Fainting:    Current  or  past?    _____________________________________________   ____Fibromyalgia   ____Fractures:    If  yes,  please  explain    _________________________________________   ____Heart  Conditions:    If  yes,  please  explain  ___________________________________   ____High  Blood  Pressure   ____High  Cholesterol   ____Joint  Problems:    If  yes,  please  explain    ___________________________________   ____Menopause   ____Migraines   ____Muscle  Cramps   ____Multiple  Sclerosis   ____Osteoporosis/Osteopenia   ____Scoliosis:    Type  of  curvature    ____________________________________________   ____Seizures   ____Shortness  of  Breath   ____Stroke:    If  yes,  date?    __________________________________________________   ____Thyroid  Disease:    Hyper  or  Hypo?    _______________________________________   ____Vertigo     Are  there  any  other  conditions  that  we  may  need  to  be  aware  of  to  safely  engage  you  in   an  exercise  program?     ________________________________________________________________________ ________________________________________________________________________     Are  you  presently  doing  other  kinds  of  therapy?       ____Acupuncture   ____Chiropractic   ____Massage   ____Physical  Therapy   ____Rolfing   ____Other:    _____________________________________________________________  

Fitness  History     What  is  your  primary  reason  for  visiting?    What  do  you  want  to  gain  from  Pilates?     ________________________________________________________________________     What  are  your  general  fitness  goals?         ____Back  Pain  Relief   ____Gain  Strength   ____Improve  Posture   ____Increase  Energy   ____Increase  Flexibility   ____Injury  Recovery   ____Stress  Reduction   ____Toning   ____Weight  Loss   ____Other:    _____________________________________________________________       Do  you  currently  work  out  on  a  regular  basis?    _________________________________     If  yes,  Please  describe  type,  frequency,  and  duration     ________________________________________________________________________ ________________________________________________________________________     Has  any  exercise  program  had  any  positive  or  negative  effects  on  your  body?     ________________________________________________________________________ ________________________________________________________________________     Please  list  any  recreational  activities  or  hobbies   ________________________________________________________________________ ________________________________________________________________________      Do  you  have  any  past  Pilates  training?    If  yes,  where  and  what  is  your  experience?   ________________________________________________________________________   ________________________________________________________________________      Is  there  anything  else  you  would  like  your  Pilates  instructor  to  know?   ________________________________________________________________________ ________________________________________________________________________