Your Answers Will Help Me to Design a Class Program with Some of Your Specific Goals

Your answers will help me to design a class program with some of your specific goals, needs and/or concerns in mind. If at any time any of your information changes, please feel free to help me update your file.

Name: ______Occupation: ______

Phone: ______Email:______

Address: ______City ______Zip ______

Emergency contact name: ______Phone: ______

Your date of Birth: ______Age: ______

How did you hear about K.Pilates Studio?

Friend/Client ______Name: ______Facebook ______

Internet search ______Other ______

Please describe any experience you have had with Pilates.

What goals and/or expectations would you like to work on with your Pilates Program?

Please explain pre-existing conditions and concerns:

Pilates exercise during pregnancy can be beneficial to your physical health and delivery.

Are you currently pregnant? ______Plan on getting pregnant in the near future? ______

How many children do you have? ______How many/if any delivered C-section? ______

Have you ever been treated by a Physician for:

_____ Arthritis _____ Osteoporosis _____ Rheumatoid Arthritis

_____ Lung Disease _____ Asthma _____ Bronchitis or Emphysema

_____ Diabetes _____ Neuropathy _____ Glaucoma

_____ Chronic Fatigue _____ Fibromyalgia _____ Gastric Reflux

_____ High Blood Pressure _____ Heart Disease _____ Wearing a Pace Maker?

_____ Dizziness _____ Headaches/Migraines _____ Spondylolisthesis

_____ Stenosis _____ Facet Joint Syndrome _____ Herniated or Bulging Disc

_____ Orthopedic/Joint (shoulder/elbow/spine/hip/knee) Problems?

_____ Anterior Cruciate Ligament Knee Injuries

_____ Total Hip Replacement or Knee Replacement

Prior Injuries, Musculoskeletal and Neuromuscular Issues:

_____ Adhesive Capsulitis (frozen shoulder) _____ Rotator Cuff Impingement

_____ Carpal Tunnel syndrome _____ Plantar Fasciitis

_____ Other (please explain)

Current Activity Level/Exercise Frequency: