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Part 1. Personal Details
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
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Other
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Phone Number
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Mobile
E-mail
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Confirmation Email
Date of Birth
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Please select a month
January
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31
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2025
2024
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2022
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2020
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Part 2. Fitness experience & goals
On a scale of 1-10 how would you rate your current physical fitness?
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1
2
3
4
5
6
7
8
9
10
Describe your current fitness routine.
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Describe the fitness routine you had during the healthiest period of your life. When was this?
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Describe the health & fitness goals you wish to achieve through Pilates.
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What is the biggest challenge that you must overcome in order to achieve above goals?
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Do you have prior experience with Pilates?
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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?
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Please Select
1 Session
2 Sessions
3 Sessions
4 Sessions
5 Sessions
6+ Sessions
Please Choose
Part 3. Medical History
Have you ever suffered from...?
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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.
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3.
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4.
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Do you suffer from back pain?
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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 Select
0-2
2-4
4-6
6-8
8-10
10+
Please Choose
How much time do you spend in a seated position per day?
*
Please Select
0-2
2-4
4-6
6-8
8-10
10-12
12-14
14+
Please Choose
Do you consider yourself to be under any stress?
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Yes
No
How were your referred to Bodytonic Pilates?
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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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