Client Profile and Medical History Form
Name Date
Preferred Phone Secondary Phone
E-mail
Address
Occupation Date of Birth
How did you hear about Life Cycle Pilates? Who referred you?
Do you have any injuries, aches, pains, or health conditions? Are they current or past?
Please check any that may apply:
Cancer - Describe
Back Pain – Describe
Recent Surgeries – Describe including dates
Current or Past Smoker - Duration Packs per Day
Current Medications
Do you have any other health concerns you’d like to share?
Are you presently doing other kinds of therapy? E.g. massage, physical therapy, chiropractic
Are you or have you been active in any sports, exercise programs, physical activity? Please describe
type and frequency.
What does your typical day involve physically? E.g. sitting at computer, lifting, standing for long
periods, caring for children . _____________________________________
Do you have any past training in the Pilates method of movement? If yes, where and what is your
experience?
What are your goals? What do you want most from your Pilates experience?
Is there anything else you’d like your Pilates instructor to know?__
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Life Cycle Pilates
Please Fill Out Form and Click Submit Button Below
