Client Info + Waiver

Please fill out this form prior to your first session.

First name

Last name

Email

Date of Birth

Please check any and all that apply to you:

Neck/Back Problems

Knee Problems

Shoulder Problems

Hip Problems

Heart Condition

High/Low Blood Pressure

Osteoporosis

Stroke

Dizzy Spells

Asthma

Seizures

Arthritis

Surgery

Whiplash

Fractures

Prenatal/Postpartum

Scoliosis

Other

When exercising, including climbing stairs, do you experience any of the following?

Chest pain

Pressure over heart

Dizziness

Shortness of breath

Leg aches

Tired out feeling

Other

If you answered other to any question, please elaborate

In this section, please describe any additional health concerns, history, medications, or other factors that could affect your practice of Pilates.

Height

Weight (approximate)

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

2101 nw 81st street
clive, ia 50325

515.979.0220

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