Client Profile – Personalized Pilates

Please Complete Our Client Profile Questions

Full Name*
First Last
Email*
Mobile Phone*
Home Phone
Work Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Date Format: MM slash DD slash YYYY
How did you hear about us?*
Have you done Pilates before? If so, where? (Please check all that apply)*
- No, I have never tried any form of Pilates
- Yes, I have done Mat Pilates before
- Yes, I have done private lessons on Pilates equipment
- Yes, I have done Pilates group classes on the equipment
Where have you taken Pilates and in what format?
What other forms of movement have you experienced? (Please check all that apply)*
- Yoga
- Martial Arts
- Dance
- Group Exercise
- Cardio Machines
- Weight Lifting / Personal Training
- Running
- Swimming
- Gymnastics / Ice Skating
- Other
Please let us know how important the following items are to you:
Not Important at AllNot Very ImportantNeutralSomewhat ImportantVery Important
Go Down Clothing Sizes*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
Overall Toning*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
Have Fun Exercising*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
Increased Core Strength*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
Increased Flexibility*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
Better Posture*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
Get Out Of Pain*
- Not Important At All
- Not Very Important
- Neutral
- Somewhat Important
- Very Important
How active would you say you are?*
- Not Athletic At All
- Sporatic Exerciser
- Weekend Warrior
- Regular Exerciser
- Competitive or Professional Athlete
How hard would you say you like to workout?*
- I've been known to vomit while exercising
- I need to sweat
- Moderate
- I need lots of breaks
- The idea of exercise is enough for me
What is your gender?*
- Female
- Male
What is your current pregnancy status? (Please check all that apply)*
- There is no chance that I am pregnant
- Yes, I am pregnant
- I am trying to get pregnant
- I have not been pregnant in the last 6 months
- I am not pregnant, but I am lactating
Have you ever given birth?*
- No, I have never given birth
- Yes, all vaginally
- Yes, at least one birth was a cesarean section
What is your age?*
- Under 18 years of age
- 18 - 29 years of age
- 30 - 39 years of age
- 40 - 49 years of age
- 50 - 59 years of age
- 60 - 69 years of age
- 70 - 79 years of age
- 80 - 89 years of age
- 90+ years of age
Do you have Osteoporosis or Osteopenia as diagnosed by a bone scan?*
- I have never had a bone scan
- I have had a bone scan and do not have Osteoporosis/Osteopenia
- I have had a bone scan and I have Osteopenia
- I have had a bone scan and I have Osteoporosis
Do you have any of the following conditions? (Please check all that apply)*
- Arthritis
- Spinal Stenosis
- Spondylolithesis
- Disc Bulges/ Herniation/ Ruptures
- Sciatica
- Joint Replacement
- Limb Amputation
- Joint Fusion
- Diabetes
- Heart Disease or Heart Attack
- High Blood Pressure
- Low Blood Pressure
- Chronic Headaches or Migraines
- Neurological Condition
- Autoimmune System Disease
- I have none of these conditions
- Other
Have you ever been told you have scoliosis?*
- Yes, it is mild
- Yes, it is severe
- No, but I suspect I may have some degree of scoliosis
- No
Have you had problems with any particular joints in the last year to where you could not use them (sprain, arthritis, bursitis, etc.)? (Please check all that apply)*
- Neck
- Shoulders
- Upper Back
- Lower Back
- Elbows
- Wrists / Hands
- Hips
- Knees
- Ankles / Feet
- I have not had any problems with my joints in the last year
- Other
Do you have any conditions that currently cause you pain? If so, please briefly describe them below.*
Are you currently taking any pain medication on a regular basis?*
- No, I do not take any pain medication on a regular basis
- Yes, I do regularly take pain medication
Are any of the following a problem for you? (Please check all that apply)*
- Following auditory cues
- Doing complicated coordinated movements
- Being upside down
- Losing my balance
- Dizziness
- Being up high
- Manual cueing
- Hearing voices in a crowd
- Focusing my attention for periods of time
- None of these bother me
- Other
What is your ideal Pilates schedule? How many times per week as well as specific days and times?*
Are you a Pilates instructor or are you interested in becoming a Pilates instructor?*
- I am a Pilates instructor
- I am not a Pilates instructor, but I am interested in becoming one
- I am not a Pilates instructor and I am not interested in becoming one at this time
- I am in the process of becoming a Pilates instructor
What is your occupation?*
Is there anything else we need to know about you or any limitations you may have?*

They love up to their name. … personalized and compassionate treatment by everyone from the first encounter. I’ve been there twice and already I would recommend to anyone. Beautiful studio, great instruction, beautiful energy of all of the staff, superb customer service! I even received a handwritten thank you card after my first visit! Go try them out!

Deborah Watts

October 21, 2019

I visited for Pilates training at this studio, they are absolutely amazing. Dedicated to the practice, and definitely know what they are doing. If you are unsure about fitness because of physical limitations, try out Pilates with a well-trained instructor – your life will dramatically improve!

Tatiana Temple

May 27, 2019

I have been taking private lessons at Personal Pilates for 7 years. The quality of the instructors is excellent! I am very pleased with their attention to detail relating to my form. I feel great and pilates has certainly helped my posture, strength and golf game. The instructors make me feel like part of their family and have a strong investment in my physical success!!

Gwen Schatz

November 11, 2019

I have been taking private lessons at Personalized Pilates with Cindy for the past year and a half! I LOVE it! Cindy is an amazing instructor! She is so…

Ginny N.

November 5, 2019

Great service and the instructors are great. Very focused on the client. Also, fairly priced.

Robyn B.

November 5, 2019

I have been training at Personalized Pilates for almost 15 years! The Apprentice Private program is what keeps me coming back year after year. Each Instructor exhibits broad-based knowledge of multiple pieces of equipment; reformer, chair, spine corrector, ladder barrel, etc., making every session individualized, fresh and challenging.

Michelle Bucci

October 28, 2019