CLIENT REGISTRATION FORM

Name

First

Last

Email *

Phone # *

Postal Code *

Do you have previous Pilates experience? If yes, please describe. *

What are your regular physical activities? *

Do you have any injuries, conditions, aches or pains, that we should be aware of? *

Are you referred by a physiotherapist, chiropractor, doctor or other clinician? *

If Yes, Clinician name and location

How did you find us? *

What is your general availability (day of week and time of day) for your appointment?

What area(s) of the body is problematic?

Have your ever seen a doctor, physiotherapist or other clinician for this problem?

Is the pain constant or does is fluctuate?

What, if anything, exacerbates the pain? (eg. sitting, standing)

What, if anything, decreases the pain?

Is it worse in the morning or as the day progresses?

When did you first experience pain in the affected area?

Do you wear orthotics?

When were they first prescribed?

Is there anything else we should know?

Checkboxes

Checkboxes

Liability Waiver

Please complete and submit the Liability Waiver prior to your session.

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