Skip to content
What We Offer
About
About Amy
About Pilates
Pilates FAQ
Initial Consult Form
BIL Blog
Contact Us
Menu
What We Offer
About
About Amy
About Pilates
Pilates FAQ
Initial Consult Form
BIL Blog
Contact Us
Loading…
Initial Consult Form
First Name
*
Last Name
*
Phone Number
Email Address
*
Street Address
Apartment, suite, etc
City
State
Post Code
Medical History
Have you or your family have any history of chronic disease; (heart disease, diabetes, cancer etc.)?
Yes
No
Do you suffer from Low / High Blood Pressure?
Yes
No
Are you currently taking any medications?
Yes
No
Have you ever had your thyroid hormone level checked?
Yes
No
Have you any family history of Arthritis or Osteoporosis?
Yes
No
Have you had a bone density scan?
Yes
No
If YES to any above please elaborate
Injuries and Health
Do you have a current injury?
Yes
No
Where do you have pain?
Are you currently seeing another Health Practioner?
Yes
No
CHIRO / OSTEO / PHYSIO / MASSAGE / DOCTOR/ OTHER
CHIRO
OSTEO
PHYSIO
MASSAGE
DOCTOR
OTHER
Other Health Practitioner
How often do you see them?
Do you consent to me calling them?
Yes
No
Name / Number
Females Only
Are you pregnant?
Yes
No
Due Date
Do you have any children?
Yes
No
How many & age
Natural or Caesarian Birth
Did you have any problems during pregnancy?
Yes
No
Problems during pregnancy?
Have you had a hysterectomy or any reproductive surgery?
Yes
No
Please elaborate
Physical Fitness
Are you currently involved in an exercise regime?
Yes
No
Please list forms of exercise
When were you last exercising regularly?
What type of duties do you perform at work or hobbies?
Rate your current physical fitness between 1-10
How important is your physical fitness between 1-10
Do you enjoy exercising
Goals
Have you ever done Pilates before?
Yes
No
Why have you decided to commence Pilates?
What aspects of your health would you like to focus on?
Core Stability
Flexibility
Posture
Tone
Strength
Stress Management
Relaxation
What are 3 main aims that you are hoping to achieve from your Pilates Program?
Privacy
*
Yes, I agree with privacy policy, terms and condition
Submit Form
Please do not fill in this field.
