NAME (First/Last)

DATE

ADDRESS/CITY/STATE/ZIP

HOME / MOBILE PHONE

WORK PHONE

EMAIL ADDRESS

BIRTHDATE

OCCUPATION

WHO SHOULD WE CONTACT IN CASE OF EMERGENCY (Name/Relationship/Phone)

Please indicate whether you experience or have experienced any of the following: Please indicate whether you experience or have experienced any of the following: HYPERTENSION HEART DISEASE CHEST PAIN METABOLIC DISORDERS HIGH CHOLESTEROL CANCER DIABETES ARTHRITIS

Describe your physical history, listing major injuries, ailments, illnesses, surgeries, pregnancies, and any other significant medical treatments. Check all body parts involved, specifying Right(R) or Left (L) where appropriate. Describe your physical history, listing major injuries, ailments, illnesses, surgeries, pregnancies, and any other significant medical treatments. Check all body parts involved, specifying Right(R) or Left (L) where appropriate. HEAD NECK SHOULDER ARM/HAND UPPER BACK MID BACK LOWER BACK RIBS ABDOMEN HIP/PELVIS KNEE ANKLE/FOOT

Describe your current physical condition. Include any medications you may be taking.

List all current sports or other activities in which you participate.

What fitness/health goals do you hope to achieve with Pilates?

How did you find out about Momentum Pilates Studio?