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Studio Policies
Cart
0
ACCOUNT LOGIN
About
OUR SERVICES
Our Instructors
Our Method
BIPOC SCHOLARSHIP
CONTACT
Studio Policies
FULTON ST REFORMER SCHEDULE
REQUEST A SESSION
PRICING
Pilates On Demand
Client Profile & Medical History
Name
*
First Name
Last Name
Pronouns
*
Email
*
Phone
*
Country
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
DOB
*
MM
DD
YYYY
Occupation
How did you hear about Fort Pilates?
*
Do you have any injuries, aches, pains or health conditions?
Are they current or past?
Please check any conditions that may apply:
High Blood Pressure
Heart Problems
Muscle Cramps
Shortness of Breath
Diabetes
Joint Problems
Pregnancy
Vertigo
Fractures
Chronic Illness
Chronic Fatigue
Menopause
Seizures
Asthma
Osteoporosis
Scoliosis
Cancer
please describe in full
Chronic Back Pain
please describe in full
Past Surgeries
please describe and include dates
Cigarette Smoker?
Yes, more than one pack a day
Yes, less than one pack a day
No
Current Medications
Do you have any other health concerns you'd like to share?
Are you presently receiving other kinds of therapy?
E.g. massage, physical therapy, chiropractic
Are you or have you been active in sports, exercise programs or other physical activity?
*
Please describe type and frequency
What does your typical day involve physically?
*
E.g. sitting at computer, lifting, standing for long periods, caring for children, etc.
Do you have any past Pilates and/or Gyrotonic training?
*
If yes, where and what is your experience?
What are your goals and what do you wish to gain from your Pilates practice?
*
Is there anything else you'd like your Pilates instructor to know?
Thank you! We look forward to seeing you for your session!
