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Pilates Informed Consent -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Date of Birth

Date
Q4

Age
Q5

Gender
Q6

Email
Q7

Phone Number
Q8

Address

Street Address
Q9

Address

Street Address Line 2
Q10

Address

City
Q11

Address

State / Province
Q12

Address

Postal / Zip Code
Q13

Weight (lbs)
Q14

Height (cm)
Q15

Waistline/Abdomen (cm)
Q16

Emergency Contact Person

First Name
Q17

Emergency Contact Person

Last Name
Q18

Phone Number of Emergency Contact Person
Q19

Minors: Name of Parent/Guardian

First Name
Q20

Minors: Name of Parent/Guardian

Last Name
Q21

Contact Number of Parent/Guardian
Q22

Have you been enrolled to any physical therapy before?
Q23

Are you currently pregnant?
Q24

Do you have any allergies?
Q25

Do you have any physical disabilities?
Q26

Do you have any cardiovascular disease?
Q27

Do you have any respiratory disease?
Q28

Do you have asthma?
Q29

Did you undergo any recent surgery?
Q30

Do you have any medical condition that you would like to share? Please take note that this information is strictly confidential.
Q31

Health Insurance Policy No.
Q32

Wellness Goals
Q33

Fitness Goals
Q34

Desired weight
Q35

Date Signed

Date
Q36

Client Signature