Full Name *

Email *

Phone *

Date of Birth (mm/dd/yyyy)*

Gender *
FemaleMaleNon-binary / third genderPrefer not to sayPrefer to self-describe

Occupation

Height *

Weight *

Do you have any Pilates experience? If so, please explain

Please Check All That Apply (current and/or past conditions) *
AsthmaNeck painBack pain (low)Back pain (mid)Back pain (upper)ArthritisHip condition/ replacementOsteopenia / OsteoporosisNeurological DisordersSpinal disordersHeart disorderHigh blood pressureHeadachesDizzyness/VertigoAbdominal/bowel disordersHearing issuesCancer/tumorsOtherNone

Please elaborate on any of the conditions you checked in the previous section:

Please list all injuries and surgeries, or pregnancies including year/ due date

Please describe any other condition that might limit your participation

Do you adhere to a consistent diet?

Do you exercise regularly? If so, how often? What type?

What are your health and fitness goals?

Is there anything else you wish to let us know that will better help us work with you?

I hereby grant Candlestick Pilates the right to take and use my Photo for any lawful
purpose such as; social media, marketing, and website content.

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Client Signature*