contact information and health questionnaire Please fill out and submit this form in advance of your first visit. Contact Info Name * First Name Last Name Date of Birth * MM DD YYYY Email Address * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name (###) ### #### Would you like to be added to the newsletter? Yes please No thank you Height * Weight Current and/or Past Conditions (please check any/all that apply) * Herniated, bulging or slipped disc(s) Osteopenia/Osteoporosis Arthritis Stenosis Scoliosis Spondylolisthesis or Retrolisthesis Knee pain Heart disorder Asthma Back/Neck pain Abdominal/Bowel disorder High Blood Pressure Cancer/Tumors Other None If "other", please elaborate Are you taking any medications for the above conditions? Yes No Please list any physical injuries or surgeries (include year) Are you pregnant or expecting to become pregnant? * Yes No NA Are you a regular smoker? Yes No How many years experience do you have practicing Pilates? * No experience, this is my first time Less than a year 1-5 years 5+ years Tell me your goals * What are you looking to achieve by taking Pilates? Thank you!
