Reformer/Mat Pilates Private Intake Form

First & Last Name (required)

Today's Date (required)

Your Email (required)

Your Phone Number (required)

Emergency Contact (Name & Phone Number)

Overall Health (required)
ExcellentGoodFairPoor

Additional health notes you'd like to share

List any current medications

Do you have your doctor or PT's permission to exercise? (If no, please explain)

Have you had any surgeries or injuries in the past year? If yes, please describe

Frequency of physical activity
NoneOccasionallyMonthlyWeeklyDaily

Please list your current physical activities

Pilates goals - check all that apply (required)
Post Surgery/Rehab/Injury AccommodationImprove balance build strengthImprove practice/specific skill buildingIncrease mobility/range of motionImprove postureOther

Availability for 60 or 90-minute session: please provide a range of days/times when you’re available, along with a preferred time slot

Teacher Preference (Note: this teacher may not be available, but we’ll try our best. Leave blank if you would like us to recommend a teacher based on your needs)

Do you currently experience or have you experienced any of these conditions in the past?
ArthritisBack painHeart condition/heart attackHigh/low blood pressureHerniated/bulging discSpinal stenosisOsteopenia/osteoporosis pregnancyNumbness in arms/legsNeurological conditionDiabetesJoint replacementHistory of fallsOtherNone of these

Please list any areas of your body where you currently feel pain, tension or soreness

If you are currently seeing a PT or physician, please provide their contact information

Thank you for completing the Reformer/Mat Pilates Private Intake Form, please give our staff up to 7 days to contact you for scheduling.