DBP Intake Form • Dynamic Body Pilates

Welcome to Dynamic Body Pilates!

- Step 1 of 5

Please complete and submit the DBP intake form prior to your session.

We can't wait to get started helping you to rediscover mobility, fitness & ease!

Please fill in your name: *

First

Last

Phone Number *

Best email to be contacted at: *

Mailing address (please complete all fields) *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Are you currently cleared by your physician to participate in an exercise program? *

How did you hear about Dynamic Body Pilates? *

HEALTH HISTORY

Date of Birth *

What is your height (feet, inches)? *

What is your current weight (lbs)? *

Please list any current medications you are taking (if any) - particularly those with side effects: *

Are you currently pregnant? *

If Yes, how many weeks?

Optional

Have you ever had surgery? *

If Yes, please list all past injuries/conditions including dates and treatment for the injury/condition:

Optional

Do you have any medical conditions that we should be aware of (Osteoporosis, Multiple Sclerosis, Diabetes, Heart Condition, Blood Pressure, Vertigo, etc... *

If Yes, please explain:

Optional

Please identify any areas of challenge or concern: *

Abdominals
Ankles
Arms
Chest
Elbows
Feet
Glutes
Hands
Hips
Knees
Legs
Lower Back
Neck
Shoulders
Upper Back
Wrists
Other

If Other, please explain:

Optional

Do you have any "old" injuries that do not currently bother you? (Please describe if applicable)

Optional

Are you currently working with any of the following practitioners?:

Massage Therapist
Acupuncturist
Chiropractor
Physical Therapist
Naturopath
Nutritionist
Coach
Other

Optional

If any, please list the person(s) or practice(s) you visit, what prompts a visit, and frequency of visits:

Optional

FITNESS

What are your fitness goals? *

How frequently do you exercise? *

0 days per week
1-3 days per week
4+ days per week

Have you practiced pilates before? *

If Yes, were they private or group classes?

Optional

Have you ever tried any other mind-body movement modalities (check all that apply)?: *

Alexander Technique
Feldenkreis
Gyrotonics
MELT
Yoga
Other
None

Please provide frequency and location for any of the above:

Optional

Have you ever worked with any type of personal trainer before? *

If Yes, please provide frequency and experience:

Optional

What do you like about exercise? *

What do you dislike about exercise? *

What is your biggest physical challenge, concern or obstacle right now? *

NUTRITION & LIFESTYLE

How many glasses of water do you drink per day? *

How frequently do you drink alcohol? *

How frequently do you drink caffeine? *

Are you on a diet or nutritional plan? *

If Yes, please describe:

Optional

How many hours per night do you sleep? *

Do you smoke? *

If Yes, please describe frequency:

Optional

Approximately how old is your mattress? *

In what position are you most likely to sleep? *

Are you frequently in a car or on a plane? *

Comments

Optional

Please rate the quality of the following areas of your life:

Sleep: *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

Relationships: *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

Work: *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

Social Life: *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

Home Life: *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

Creativity: *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

General Well-Being *

Could be better
No complaints
Exceptional
N/A

Please explain:

Optional

Other:

Could be better
No complaints
Exceptional
N/A

Optional

Please explain:

Optional

YOUR GOALS

What do you hope to accomplish as a result of training with Dynamic Body Pilates? *

What do you hope to accomplish for your body in the next 3 months? *

What motivates you to stay on track with your goals? *

Is there anything else you would like to share? *

The participant is aware that participation in a sport or physical exercise may result in accident or injury, and Participant assumes the risk connected with the participation in a sport or exercise and represents that Participant is in good health and suffers from no physical impairment which would limit their use of Dynamic Body Pilates' services. Participant acknowledges that Dynamic Body Pilates has not and will not render any medical services including medical diagnosis of Participant's physical condition. Participant specifically agrees that Dynamic Body Pilates, its officers, employees, and agents shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on account of death, personal injury, property damage or loss of any kind resulting from or related to Participant's use of the facilities or participation in any sport, exercise or activity within or without the studio premises, and Participant agrees to hold Dynamic Body Pilates harmless from same.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above by typing my name here:

Name *

Signature *

Dynamic Body Pilates has a strict 24 hour cancellation policy. To avoid a charge for your session you must contact Dynamic Body Pilates at [email protected] at least 24 hours in advance of your session.

Please type your initials: *