Please Complete Our Client Profile Questions Full Name* First Last Email* Mobile Phone*Home PhoneWork PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* Date Format: MM slash DD slash YYYY How did you hear about us?*Another ClientAnother StudioBalanced BodyFacebookGoogleInstructor at our studioKatrina or Larry FoeOnline Web SearchPersonalized Pilates WebsitePilates Method Alliance (PMA)Sign on SheaSilent Auction PrizeWhole FoodsYellow PagesOtherHave 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 ImportantGo Down Clothing Sizes*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantOverall Toning*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantHave Fun Exercising*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantIncreased Core Strength*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantIncreased Flexibility*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantBetter Posture*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantGet Out Of Pain*Not Important At AllNot Very ImportantNeutralSomewhat ImportantVery ImportantHow active would you say you are?*Not Athletic At AllSporatic ExerciserWeekend WarriorRegular ExerciserCompetitive or Professional AthleteHow hard would you say you like to workout?*I've been known to vomit while exercisingI need to sweatModerateI need lots of breaksThe idea of exercise is enough for meWhat is your gender?*FemaleMaleWhat 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 birthYes, all vaginallyYes, at least one birth was a cesarean sectionWhat is your age?*Under 18 years of age18 - 29 years of age30 - 39 years of age40 - 49 years of age50 - 59 years of age60 - 69 years of age70 - 79 years of age80 - 89 years of age90+ years of ageDo you have Osteoporosis or Osteopenia as diagnosed by a bone scan?*I have never had a bone scanI have had a bone scan and do not have Osteoporosis/OsteopeniaI have had a bone scan and I have OsteopeniaI have had a bone scan and I have OsteoporosisDo 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 mildYes, it is severeNo, but I suspect I may have some degree of scoliosisNoHave 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 basisYes, I do regularly take pain medicationAre 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 instructorI am not a Pilates instructor, but I am interested in becoming oneI am not a Pilates instructor and I am not interested in becoming one at this timeI am in the process of becoming a Pilates instructorWhat is your occupation?*Is there anything else we need to know about you or any limitations you may have?* [testimonial_view id="8"] [testimonial_view id="10"] [testimonial_view id="14"] [testimonial_view id="7"] [testimonial_view id="6"] [testimonial_view id="5"]
