Atlas Pilates Client Intake Questionnaire
Confidential
Date:
First Name
Last Name
Email
Telephone Number
Mailing Address
City, State
Zip Code
What is the Best Way to Reach you?
Emergency Contact Name
Emergency Contact Telephone Number
Date of Birth
How Did You Hear About Us?
Have You Done Pilates Before?
Where was Your Pilates Experience?
Do you have Any Doctor-Ordered Activity Restrictions?
If So, Please Explain
Have You Had any Surgeries?
When was Your Surgery
Do You Have Any Injuries?
When were you Injured?
Please Describe Your Injuries:
Have You Ever Broken Bones?
Have You Had Muscle Strains or Sprains?
Have You Injured Ligments or Tendons?
Have You Injured Joints or Cartilage?
Have You Experienced Chronic Pain?
Have You Had Back Pain or Spasms?
Have You Had Injuries that Required a Doctor's Visit?
Have You Had Injuries that Required Physical Therapy?
Do You Have High Blood Pressure?
Have You Had Heart or Circulation Disorders?
Do you or Have You Ever Experience Seizures?
Have you Had Cancer?
Do you Have Arthritis?
Are You Pregnant?
Have you Given Birth?
If So, How Many Children?
Do You Exercise Regularly?
What Type of Exercise Do You Do Regularly?
How Often do you Exercise?
What kinds of Exercise do you Like Most?
Do You Participate in Any Sport?
Are you/ Have you been an Athlete?
Are you Taking any Medications?
What Medications?
Goals:
What are Your Goals?
Flexibility
Strength
Breathing Control
Sports Conditioning
Weight Loss
Stress Management
Post-Rehabilitation
How Long Do you Expect That It
Will Take for You to Reach Your Goals?