Health & Fitness History 

The Pilates Center of Baton Rouge

 

Please print, fill out this form to the best of your ability, sign at the bottom, and mail or bring in to the studio.

If you have any questions, please feel free to ask.

 

Name: __________________________________________________________        Birthdate:________________

 

Address:_____________________________________________________________________________________

 

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City_________________________________________ Zip Code _______________________________________

 

Home Phone: ____________________ Work Phone: ___________________ Cell Phone: ___________________

 

Email: ________________________________________________________________________

 

Employer:______________________________________Occupation:_____________________

 

How long is your work day?__________________Sex: M/F Marital Status:__________

 

General Health: _____Excellent _____Good _____Fair _____Poor_____

 

Previous experience with Pilates:________________________________________________________________

 

Health and fitness goals:_______________________________________________________________________

 

Hobbies and current physical activities:___________________________________________________________


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Do you currently have small children?_____________________________________________

 

Medications:___________________________________________________________________

 

Previous Injuries:____________________________________________________________________________

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Previous Surgeries:___________________________________________________________________________

 

Are you currently receiving professional health care services? If so, please explain: _______________________

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Please list any regular body work you receive, e.g., Chiropractic, Massage,etc.___________________________

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Has your doctor indicated any limitations or exclusions of certain activities? Describe:

 

Back Trouble         Joint Problems          Diabetes         Pregnant              Pelvic floor pain/weakness

 

Heart Attack          Allergies                    Stroke            Headaches           Heart Disease

 

Spinal Injury          Migraines                 Stenosis          Neck Trouble      Asthma

 

High Anxiety         Breastfeeding          Date:__________________

 

 

 

Do you have a history of? (Circle all that apply)

 

Fainting                  Seizure                    Fibromyalgia

 

 

 

Current Medical/Physical Conditions (Circle all that apply):

 

Shoulder Problems        GlaucomaI smoke       Scoliosis        Osteoporosis        Head Injury

 

Back/Neck Pain             Cancer               Knee Problems           Hyper-Hypotension      

 

Bleeding/Clotting Disorder             Dizziness during exercise              Carpal Tunnel Syndrome

 

Is there anything you feel we should know and have not asked? If so, please explain: ______________________________________________________________________________

 

______________________________________________________________________________

 

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I, THE UNDERSIGNED, DO HEREBY CERTIFY THAT I HAVE COMPLETED THE ABOVE INFORMATION AND KNOW IT TO BE TRUTHFUL AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

 

SIGNATURE: _________________________________________________________________

 

DATE:_______________________________________________________________________

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