Reforming Indy Pilates Studio
Client Profile
Client Information -
Name
Date Of Birth
Height
Weight
Occupation
Address
City,State ..Zip
Home Phone
Emergency Contact
Email Address
Cell Phone
Phone
Client History-
Please Indicate any Conditions you are currently experiencing, or have experienced.
Chronic Back Pain
Spinal Problems
Frequent Headaches
High Blood Pressure
Heart Conditions
Arthritis
Diabetes
Cancer
Operations
Epilepsy
Sprains/Fractures
Osteoporosis
Muscle Cramping/Pain
Circulatory Problems
Other
Please explain any indicated conditions or other medical relevant issues below.
Are you currently pregnant or recently given birth
No
Yes
Are you currently taking any form of medication
No
Yes
Client Goals and expectations-
Please indicate what you want to achieve by participating in Pilates, listing 3 priority goals.
Please indicate what your expectations are of your instructor.