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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? ________________________________________________________________________ ________________________________________________________________________