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Samoa
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Saudi Arabia
Senegal
Serbia
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Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
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Tonga
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Vanuatu
Venezuela
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Virgin Islands, U.S.
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Western Sahara
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Ã…land Islands
Country
Preferred Communication:
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phone
email
text
other
Occupation
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Date of Birth
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MM slash DD slash YYYY
Gender
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Female
Male
Prefer not to say
How did you hear about our Pilates studio?
*
online search
Sign on Shea
Referred by Physician/Practitioner
Advertisement
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Referred by PP Client
What is your ideal Pilates schedule? (# per week)
What are your best days/times?
Have you done Pilates before? (Please check all that apply)
*
I have never done Pilates before
I have done Pilates on the mat
I have done Pilates on the reformer
I have done chair, tower, & other equipment
I have done private (1-on-1) Pilates lessons
I have done Pilates classes on the equipment
What other forms of movement have you experienced? (Please check all that apply)
*
Yoga
Group Exercise
Cardio Machines
Weight Lifting/Personal Training
None of the Above
How important is - Going Down Clothing Sizes?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Overall Toning?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Having Fun Exercising?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Increased Core Strength?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Increased Flexibility?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Better Posture?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Getting Out Of Pain?
*
Very Important
Somewhat important
Not very important
Not important at all
Have you ever had a bone scan?
*
yes
no
Do you have Osteoporosis or Osteopenia?
*
Osteoporosis
Osteopenia
Neither
Are you currently pregnant or trying to get pregnant?
*
no
yes
trying to get pregnant
If so, when are you due?
Have you ever given birth?
*
no
yes, all vaginally
yes, at least 1 C-section
Have you ever been told you have any of the following conditions? (select all that apply)
*
Scoliosis
High/Low blood pressure
Disc bulging or herniation
Arthritis
Stenosis
Diabetes
Spondylolithesis
Joint replacement/fusion
Chronic headaches
None
Other
Are any of these a problem for you? (select all that apply)
*
Focused attention for periods of time
Being up high
Being upside down
Auditory cues
Dizziness
Loosing your balance
Manual cues
Complex coordinated movements
Hearing voices in a crowd
None
Other
How active would you say you are?
*
Not athletic
Sporadic exerciser
Weekend warrior
Regular exerciser
Professional athlete
How hard would you say you like to work out?
*
The idea of exercise is enough
I need lots of breaks
Moderately
I need to sweat
I have been known to vomit while exercising
What goals are you hoping to achieve from Pilates?
*
Please list any joints you were unable to use in the last year due to pain:
*
Do you have any conditions that currently cause you pain?
*
Are you currently on pain meds?
*
Yes
No
Δ
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Client Profile
"
*
" indicates required fields
Step
1
of
2
50%
Name
*
First
Last
Email
*
Mobile Phone
*
Home Phone
Work Phone
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Preferred Communication:
*
phone
email
text
other
Occupation
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Female
Male
Prefer not to say
How did you hear about our Pilates studio?
*
online search
Sign on Shea
Referred by Physician/Practitioner
Advertisement
Personalized Pilates website
Referred by PP Client
What is your ideal Pilates schedule? (# per week)
What are your best days/times?
Have you done Pilates before? (Please check all that apply)
*
I have never done Pilates before
I have done Pilates on the mat
I have done Pilates on the reformer
I have done chair, tower, & other equipment
I have done private (1-on-1) Pilates lessons
I have done Pilates classes on the equipment
What other forms of movement have you experienced? (Please check all that apply)
*
Yoga
Group Exercise
Cardio Machines
Weight Lifting/Personal Training
None of the Above
How important is - Going Down Clothing Sizes?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Overall Toning?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Having Fun Exercising?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Increased Core Strength?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Increased Flexibility?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Better Posture?
*
Very Important
Somewhat important
Not very important
Not important at all
How important is - Getting Out Of Pain?
*
Very Important
Somewhat important
Not very important
Not important at all
Have you ever had a bone scan?
*
yes
no
Do you have Osteoporosis or Osteopenia?
*
Osteoporosis
Osteopenia
Neither
Are you currently pregnant or trying to get pregnant?
*
no
yes
trying to get pregnant
If so, when are you due?
Have you ever given birth?
*
no
yes, all vaginally
yes, at least 1 C-section
Have you ever been told you have any of the following conditions? (select all that apply)
*
Scoliosis
High/Low blood pressure
Disc bulging or herniation
Arthritis
Stenosis
Diabetes
Spondylolithesis
Joint replacement/fusion
Chronic headaches
None
Other
Are any of these a problem for you? (select all that apply)
*
Focused attention for periods of time
Being up high
Being upside down
Auditory cues
Dizziness
Loosing your balance
Manual cues
Complex coordinated movements
Hearing voices in a crowd
None
Other
How active would you say you are?
*
Not athletic
Sporadic exerciser
Weekend warrior
Regular exerciser
Professional athlete
How hard would you say you like to work out?
*
The idea of exercise is enough
I need lots of breaks
Moderately
I need to sweat
I have been known to vomit while exercising
What goals are you hoping to achieve from Pilates?
*
Please list any joints you were unable to use in the last year due to pain:
*
Do you have any conditions that currently cause you pain?
*
Are you currently on pain meds?
*
Yes
No
Δ