Services
About
Start Now
Services
About
Start Now
Intake form
Congratulations on getting started at Pilates Advantage
Before your first session please fill out this form so we can tailor your sessions to meet your needs.
Date
*
MM
DD
YYYY
Personal Details
Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Date of Birth
*
Fitness experience and goals
On a scale of 1-10 how would you rate your current physical fitness?
*
1
2
3
4
5
6
7
8
9
10
Describe your current fitness routine.
*
Describe the fitness routine you had during the healthiest period of your life. When was this?
*
Describe the health & fitness goals you wish to achieve through Pilates.
*
What is the biggest challenge that you must overcome in order to achieve above goals?
*
Do you have prior experience with Pilates?
*
Yes
No
If yes to above, what other studios/gyms have you practiced Pilates at?
*
How many training sessions per week are you willing to dedicate towards achieving these goals?
*
1
2
3
4
5
6+
Medical History
Have you ever suffered from
*
Asthma
Arthritis
Heart disease
Headaches
High blood pressure
Diabetes
Shortness of breath
Migraines
Low blood pressure
High cholesterol
Epilepsy
Dizziness/fainting
Palpitations
None
List & date any injuries, surgeries or pregnancies.
1.
Date
*
MM
DD
YYYY
2.
Date 2
MM
DD
YYYY
3.
Date 3
MM
DD
YYYY
Do you suffer from back pain?
Yes
No
What is your ‘chief complaint’ or Major Injury?
*
Occupation & Lifestyle
Occupation. Describe physical requirements associated with your job.
How many hours do you spend in front of a computer per day?
*
0-2
2-4
4-6
6-8
8-10
10+
How many hours do you spend in a seated position per day?
*
0-2
2-4
4-6
6-8
8-10
10-12
12-14
14+
Do you consider yourself to be under any stress?
*
Yes
No
How were your referred to Pilates Advantage?
Thank you!
