Pilates Client Form

Pilates Client Form

Information & Medical Form
Full Name*

First NameLast Name
Phone Number*

Phone NumberPhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

TownState

Post Code
Emergency Contact Name

First NameLast Name
Emergency Contact Number

Area CodePhone Number
Please check the conditions that apply to you*

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyBroken BonesSpinal ConcernsMusculoskeletal DiscomfortNONE
Are you pregnant?

YesNo
What fitness and health goals do you wish to acheive through Pilates*

Increase flexiblityIncrease strengthIncrease lung capacityToningRelaxationAlignment & posutre correctionPain reliefBalance
Are you currently taking any medication?*

YesNo
Do you have any other: injuries/conditions/illnesses I should be aware of?
Do you have your doctor/GP/Specialist/Physiotherapist blessing to join Pilates classes?

YESNO
Signature

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Date

MonthDayYear
Date
Should be Empty: