Intake Form

Contact Information

Name (required)

Phone Number (required)

Address (Address, City, State, Zip)

Your Email (required)

Occupation:

Year of Birth:

How did you learn about our services?

Can we email you information about Health & Pilates?
 Yes No

Emergency Contact?

Emergency Contact Phone #

History

Have you participated in PILATES exercises before?
 Yes No If yes, how long?

What are your goals for the PILATES experience?
 Muscle Tone Weight Reduction Flexibility General Health
Other:

What type(s) of PILATES training are you interested in?
 Private Equipment Sessions Duet Equipment Sessions Mat Classes Foam Roller Classes

What other type of movement exercise or sports have you participated in before?

Do you currently have any current injuries, pain or soreness?
 Yes No If yes, Please Describe:

Are you currently under medical or therapeutic treatment?
 Yes No If yes, please explain:

Please list any current medications:

Do you have any friends or family who might like to learn about our Pilates Programs?:
Name / contact info?

For future reference, what days / times for classes would be best for your schedule

Any other information that may be helpful?

Medical History
Please check the following conditions that apply to your, past and present.

Musculo-Skeletal
 Spinal Injuries or degeneration Joint Stiffness/Swelling Spasms/Cramps Jaw pain/TMJ Tendonitis or Bursitis Stenosis Arthritis or Osteoporosis Hip Replacement Bone or Joint Disease Laminectomy Scoliosis ACL or Knee Injury

Circulatory and Respiratory
 Dizziness Shortness of Breath Fainting Cold hands or feet Blood clots Stroke Heart Condition Allergies High Blood pressure
Other:

Skin
 Allergies Other:

Other:
 Hearing impaired Visually impaired Bladder infection Diabetes Fibromyalgia Cancer
Infection Disease:

Nervous System:
 Headaches Numb/Tingling Twitching of face Fatigue Chronic pain Epilepsy Shingles
Other:

Endocrine System:
 Endometriosis Prostate problems
Other:

Digestive:
 Nervous stomach Indigestion Crohn's Disease
Other:

Other Notes

Are you Pregnant?
 Yes No

Surgeries?

Any other additional comments regarding your health and well being?

Physician Name & Phone #:

 I have noted all conditions that I am aware of and this information is accurate. I will inform my Pilates Teacher of any changes.
Your Initials:

Waiver of Liability and Informed Consent Release (required signatures)

I, wish to participate in the exercise and training program offered by MOVING MOXIE PILATES (MMP). I hereby certify that I have answered all health and medical questions honestly and completely and have no health issues that effect my ability to safely participate in the practice of Pilates. I further acknowledge that I will consult with my physician if I have any concerns about my safe participation in Pilates classes offered by Moving Moxie Pilates.

I understand that I am not obligated to perform or participate in any activity that I do not wish to do, and that it is my right to refuse participation at anytime during my training sessions for any reason.

I understand the results of my fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.

I understand that if I arrive late, there is no guarantee that I will receive the full session time with my instructor, and that if I miss a class without 24 hour notice, there is no promise of a refund.

I understand that MMP bills clients on a pre-pay basis, and that once I have decided on the type of training plan to participate in, payment is due before sessions begin.

I understand that during a session Touch Training may be used to correct alignment and/or to focus my attention on a particular muscle area, and that if I am uncomfortable in any way with instructors touching me that I will notify them to discontinue this training element immediately.

I hereby authorize MMP and its instructors to act on my behalf in the event that I am a victim of an accident, sudden illness, or injury that occurs on the premises of MMP. Actions on my behalf shall include but not be limited to calling for emergency care, administering CPR, or seeking any help and advice they deem appropriate for medical care.

I agree that MMP and its instructors will not be liable or responsible for any injuries resulting from participation in their programs. I expressly release and discharge MMP and it’s employees, investors, teachers, contractors, consultants, landlord, agents and or assigns from all claims, actions, judgments, and the like that I or my heirs, executors, administrators, or assigns my have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program or my use of the facilities, including damages which are caused or alleged to be caused, in whole or in part, by the negligence of MMP or it’s employees, investors, teachers, contractors, consultants, landlord, agents and or assigns, excepting only intentional acts of such person or persons.

I will allow any or all pictures of myself in the studio to be used by Moving Moxie Pilates LLC for marketing material unless duly noted here by myself and Moving Moxie Pilates.

I have thoroughly read this Waiver of Liability and Informed Consent Release and understand all of its terms. I sign this agreement voluntarily and with full knowledge of its significance.

Signed,
Date (mm/dd/yyyy):

Thank you!

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