New Client Intake

Date *

Month Day Year
Part 1. Personal Details
Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *
Mobile
E-mail *

Confirmation Email
Date of Birth *

Month Day Year
Part 2. Fitness experience & 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? *
Please Choose
Part 3. Medical History
Have you ever suffered from...? *

Asthma High Blood Pressure Low Blood Pressure Epilepsy Arthritis Diabetes Frequent Colds Dizziness/fainting Heart Disease Shortness of breath High Cholesterol Palpitations Headaches Migraines NONE
List & date any injuries, surgeries or pregnancies.
1. *
Date

Month Day Year
2.
Date

Month Day Year
3.
Date

Month Day Year
4.
Date

Month Day Year
Do you suffer from back pain? *
What is your ‘chief complaint’ or Major Injury? *
Part 5. Occupation & Lifestyle
Occupation. Describe physical requirements associated with your job. *
How many hours do you spend in front of a computer per day? *
Please Choose
How much time do you spend in a seated position per day? *
Please Choose
Do you consider yourself to be under any stress? *

Yes No
How were your referred to Bodytonic Pilates? *
Please Read and Agree to the Following Terms & Conditions.
1.) CANCELLATIONS Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client. 2.) LATE ARRIVALS Each session shall be 50-55 minutes in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client. 3.) EXPIRATIONS Unless othewise noted, all monthly memberships, packages, and series expire 4-weeks from the 1st class in the membership, package, or series 4.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential. I AGREE TO THE ABOVE TERMS & CONDITIONS *

I agree to the above terms.
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Part 1. Personal Details

Part 2. Fitness experience & goals

Part 3. Medical History

Part 5. Occupation & Lifestyle

Please Read and Agree to the Following Terms & Conditions.