New Client Intake Form Client Information Name * First Name Last Name Birthdate * Address * Mobile Phone Number * Alternate Phone Number Email * Emergency Contact Information Contact's Name * First Name Last Name Relationship to Client * Emergency Contact Phone Number * Intake Questions Why are you interested in working together? * Why are you seeking movement education (Pilates, yoga, continuing education, etc.) at this time? What are your current activities? * example: yoga, hiking, weights, none What do you see as your current limitations? * example: pain, injury, time management, lack of motivation Have you been cleared by your doctor to participate in an exercise program? Yes No If there are any health professionals (doctor, chiropractor, acupuncturist, etc.) whom you would like me to consult with regarding any injuries or limitations, please list their names and contact information. Please sign your name in full to acknowledge your agreement to this dialogue. Do you have any previous injuries or surgeries you would like to mention? * Are you taking any current medications that might affect your exercise needs or endurance? * example: blood pressure medication Have you been diagnosed with osteoporosis or osteopenia? * No Yes, and I am taking medication Yes, but I am not taking medication Are you currently pregnant? No Yes, it's my first Yes, and my previous deliveries were vaginal Yes, and my previous deliveries were c-sections Any previous complications with previous pregnancies? Is this anything else you wish to share or would like me to know about you? Thank you for taking the time to prepare for our first session!
