Client Intake Form Name: * Birthdate: * Gender: * MaleFemalePrefer not to disclose Occupation: * Street Address: * Postal Code: * State/Province: * Country: * Dr/Specialist & Tel: * Physio/Chiro & Tel: * Phone (Home): Phone (work): Phone (Correspondence): * Other Practitioner & Tel: Email: * Emergency Contact Details Full Name: * Contact Number: * Email Address: * Health History: Please indicate condition experienced presently or in the past. Has your doctor ever said that you have any sort of heart trouble or defect? * YesNo If Yes, please explain: Have you ever been told you have arthritic joints OR any bone/joint problem which may be exacerbated by exercise? * YesNo If Yes, please explain: Have you had an operation/injuries/pregnancy in the last year or more? * YesNo If Yes, please explain: Is there any good reason that should stop you from performing physical exercise? * YesNo If Yes, please explain: Do you suffer from neck, back, or any other ache? * YesNo If Yes, please explain: For the following questions, please select a scale from 0 - low to 10 - high Place the level /frequency of your pain: * 012345678910 When is your pain at its worst?: Place your level of energy: * 012345678910 When is your energy at its best?: Are there any movements that cause you pain? (ex. Raising your arms, bending forward or to the side, etc.) * Are you currently taking any medication? (Please state reason and dosage) * Have you suffered from cancer, diabetes, allergies, asthma, other condition? * Blood Pressure * HighLowNormal Do you Smoke? * YesNo Current activity level Do you currently exercise? What type? How Often? * Please give a brief description of your exercise history: * Pilates History Have you done Pilates before? * If Yes, where and how long for? What type of class did you attend? * PrivateGroup ClassVirtual How did you hear about Live2Thrive Pilates? Signature Participant: (Print Name) * Date of Signature: *
