New Client Form Name * First Name Last Name Email * Phone * (###) ### #### Birthday Gender/Pronouns Injury History Past or current injuries, Sx, illness, or medications that impact your movement, balance, or coordination Current Medical Conditions: Arthritis/OA/RA Chronic Fatigue Syndrome Diabetes Fibromyalgia Heart Disease High Blood Pressure Gastric Reflux Glaucoma/Eye Pressure Conditions Neuromuscular Conditions (MS, Parkinson's) Osteoporosis/Oseopenia Peripheral Neuropathy/Nerve Damage Pregnant (currently) or Post-natal (recently) Vertigo/Dizzyness Other (please specify above) None Orthopedic Conditions: Adhesive Capsulitis (frozen shoulder) or Impingement Cervical Radiculopathy Carpal Tunnel Syndrome or other Wrist Pain/Pathology Thoracic Outlet Syndrome Spondylolisis/Spondylolesthesis Herniated Disc/Bulging Disc (specify spine level above) Chronic Low Back Pain (cLBP) Scoliosis Hip Labrum Tear or Labral Degeneration Bursitis (specify type above) Knee Injuries (ACL, PCL, MCL, Meniscus) Ankle/Foot/Plantar Fasciitis Joint Surgery (full replacement/partial or repair) Hypermobility (EDS/HSD) Other (please specify above) None Exercise History and Goals Please describe: current goals for Pilates, prior exercise experience, and current exercise Message Cancellation Policy and Refunds * A 48-hour cancellation policy is enforced for all sessions. While we understand there are some unavoidable circumstances, late cancellations, re-scheduling within 48-hrs, or no-shows will be charged the full session fee. If you are contagious, please be considerate and notify your teacher and do not come into the studio. Refunds for sessions or packages are not administered after payment and will expire within 1 year from date of purchase. Sessions without payment on file may be canceled. I agree to the 48-hr cancellation policy I agree to the expiration/refund policy I attest I am cleared for physical activity and take full responsibility for my physical condition Thank you for submitting the form! I look forward to working with you.
