new client profile by X1dh07


									                                      Client Profile
First Name:
Last Name:
City:                                               State:                     Zip:

*Email Address:                                              Emergency Contact:
Cell Phone:                                                  Relationship:
Home Phone:
                                                             Phone Number:
Work:                                  Ext:
Birth Date:                                                  E-mail Address:

        How did you hear about us?
         Google             Website                 Newsletter                       Facebook
         Newspaper            Postcard              Door-hanger                      Street Sign
         Fundraiser           Referral:                      Other:______________
         Friend:
        What are your exercise goals? Number the following exercise benefits according to their
        importance to you. (One being the most important)
            Weight Loss                  Posture                    Stress Reduction
            Increase Strength                      Flexibility                        Other
            Cardiovascular Conditioning
        Are you interested in:
         Privates              Semi-Privates        Reformer Class                   Mat Class
         Cardio Pilates       Pregnancy Package Dance Conditioning                   Other
     In order to design a safe and effective fitness program it is important that you complete the
     following Health History. It is crucial that you answer all the questions honestly and to the best of
     your ability. Please be advised that all information is kept strictly confidential.

A.      Check the appropriate response. Read all questions thoroughly:                  YES            NO
  1. Has your doctor ever told you that you have heart problems?
  2. Has your doctor ever told you that you have high blood pressure?
  3. Have you ever had a stroke or heart attack?
                                        Client Profile
     4. Have you ever had pain in your chest?
     5. Do you ever feel faint or have dizzy spells?
     6. Have you had surgery in the last six months?

B.      Check the appropriate conditions:
        Diabetes                      Epilepsy                            Blood Pressure
        Asthma                        Arthritis                           High Cholesterol
        Heart                         Pregnancy

C.      Have you injured or have had pain in the following areas? Check the appropriate lines.
        Neck                            Upper Back                            Shoulders
        Elbows                          Lower Back                            Hips
        Wrists                          Knees
        If yes, please explain.

F.       What is your current exercise level?
         None                     2-3 times per week                      4-5 times per week
         What type?

                                       Release of Liability
In signing below I agree that The Pilates Place is in no way responsible for the safekeeping of my
personal belongings while I attend class. I understand that classes at The Pilates Place may be physically
strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury,
property, loss or death. I agree that neither I, my heirs, assigns or legal representatives will sue or
make any other claims of any kind whatsoever against The Pilates Place or its members for any
personal injury, property, damage/loss, or wrongful death, whether caused by negligence or otherwise.
Client signature:                                         Date:
Print Client name:

        Please be advised that certain health restrictions may require you to obtain medical clearance from your
        physician before training can begin.

                                          Cancellation Policy
                             For optimum results, keeping a regular schedule is advised.
                All cancellations must be made 24 hours in advance or the session will be charged.
                          Client Profile
               There are no refunds except in cases of physical disability.
        Beginning any exercise program should be with your physician’s approval.

Name: ________________________________________________ Date: __________

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