Intake Form

Name *

First Name

Last Name

Phone Number

(###)

###

####

Any prior surgeries? *

Yes

No

Are you pregnant? *

Yes

No

Any past injuries? *

Yes

No

Chronic pain? *

Yes

No

Acute pain? *

Yes

No

Exercise? *

Do you exercise regularly?

Yes

No

How is your diet, your nutrition? *

Great

Good

Fair

Poor

Do you take any medications? *

Yes

No

Do you take any vitamins or supplements? *

Yes

No

Heart Condition *

Yes

No

Diabetes *

Yes

No

Osteoporosis *

Yes

No

Asthma *

Yes

No

Shortness of Breath *

Yes

No

Fibromyalgia *

Yes

No

Multiple Sclerosis *

Yes

No

Stenosis *

Yes

No

Spondylolisthesis *

Yes

No

Facet Joint Syndrome *

Yes

No

Dizziness *

Yes

No

Arthritis *

Yes

No

Hernia *

Yes

No

Sacroiliac Issues *

Yes

No

Angina *

Yes

No

Peripheral Neuropathy *

Yes

No

High Blood Pressure *

Yes

No

Orthopedic/Joint Issues *

Yes

No

Knee Issues *

Yes

No

Hip Replacement *

Yes

No

Back Pain *

Yes

No

What class are you interested in taking?

Dance

Pilates

Yoga

Somatics

Have you ever taken this class before?

Yes

No

What session are you interested in taking?

Somatic

Athletes + Dancers

Youth

Auto Immune

Pilates Equipment

Have you ever taken this session before?

Yes

No

Date *

MM

DD

YYYY