The Pilates Center

Client Information Form


Welcome! Our mission is to empower you to be in control of your own health and well being through the Pilates method. To better serve you, we ask that you please take a few minutes to complete this form. Thank you.

Please complete all appropriate fields below. Shaded fields are required.

Name:

Birth Date:

Occupation:

Street Address:

City, State/Province:

ZIP/Postal Code, Country:

Home Phone:

Cell Phone:

Email:


1. What specific fitness or health goals do you hope to achieve through the Pilates method?

Work target area:

Medical reason:

Other:


2. List all current and any meaningful previous activities.

Other: 


3. Describe your present physical condition.


4. Describe your physical history.

Injuries/Surgeries:

Ailments/Illnesses:

Pregnancies:

Other:

 

Please specify which areas of your body were affected Right ( R ) or Left ( L ).

Head

Neck

Shoulder

Arm/Hand

Upper back

Mid back

Lower Back

Ribs

Abdomen

Hip/Pelvis

Knee

Ankle/foot

Other:

5. How did you find out about The Pilates Center? If applicable please include the name of the person who referred you (friend, doctor, physical therapist, etc.).

Friend:

Doctor:

Other:

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The Pilates Center http://thepilatescenter.com
Signature Certificate
Document name: Client Information Form
Unique Document ID: db4e540ab43520a38bafc1621b7b3d81f5c66fc7
TimestampAudit
2016-06-01 09:02:38 MDTClient Information Form Uploaded by Rachel Taylor Segel - forms@thepilatescenter.com IP 50.194.156.193, 50.194.156.193