Pilates Client Form
Information & Medical Form
Full Name
*
First Name
Last Name
Phone Number
*
-
Phone Number
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
Town
State
Post Code
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
-
Area Code
Phone Number
Please check the conditions that apply to you
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Broken Bones
Spinal Concerns
Musculoskeletal Discomfort
NONE
Are you pregnant?
Yes
No
What fitness and health goals do you wish to acheive through Pilates
*
Increase flexiblity
Increase strength
Increase lung capacity
Toning
Relaxation
Alignment & posutre correction
Pain relief
Balance
Are you currently taking any medication?
*
Yes
No
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?
YES
NO
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SUBMIT
Should be Empty: