Health History
Name:
Address:
Phone:
cellworkhomeDate:
Birthdate:
Age:
Occupation:
Emergency Contact:
Name: Relationship: Number:Have you ever done Pilates?
If so, where and for how long?
Do you exercise regularly?
If so, what, and how often?
Are you presently under a doctor's care?
If so, for what reason?
Are you presently taking any medications?
If so, what, and for what condition?
Has a health care practitioner placed any restrictions
on how you move?
(Ex: no arching, no rounding, no lifting, or other...)
Please list any current or past injuries including surgeries
What goals would you like to achieve through Pilates?
RELEASE
I, the undersigned, hereby release Kim Reis from any liability resulting from harm incurred during instruction. I agree that I am financially responsible for payment of my Pilates lessons on or before the day of my appointment. In addition, I agree to give 24 hours notice for cancellation of an appointment. Should I fail to give adequate notice, I agree to pay for each missed visit. Pre-paid lessons are valid for three months from date of purchase.
Signature: ___________________________________________________________________________________
Date: _______________________________________________________________________________________
Email:
