New Client History Form

The first step in fitness, recovery, and well being is for us to know all about your concerns, pain, symptoms and goals. Please assist your Pilates instructor by answering the following questions as completely and accurately as possible. The information gathered will allow us to provide you with a safe and effective fitness program. We also require knowledge of your past medical history which is kept completely confidential.

Thank you for your cooperation. If you have any questions or concerns with any part of this form, you may leave it blank and ask your Pilates instructor.

Contact/Identifying Information

[form to=”lencolapilates@gmail.com” subject=”New Client”] [form_element type=”text” validate=”required” options=”” placeholder=”First Name”]
[form_element type=”text” validate=”required” options=”” placeholder=”Last Name”]
[form_element type=”text” validate=”required” options=”” placeholder=”Date of Birth”]
[form_element type=”select” validate=”” options=”Female, Male, Trans(sexual or gender)” placeholder=”Sex”]
[form_element type=”text” validate=”email” options=”” placeholder=”Email”]
[form_element type=”text” validate=”phone” options=”” placeholder=”Phone Number”]

Interests/Goals

[form_element type=”select” validate=”” options=”private training, group training, post-natal assessment, pre-natal fitness, exercise therapy/re-education, postural assessment” placeholder=”What service interests you?”]
[form_element type=”text” validate=”required” options=”” placeholder=”What is your occupation”]
[form_element type=”textarea” validate=”” options=”” placeholder=”Please describe anything at work that influences your injury/pain (e.g. prolonged sitting, physical job demands, stress levels).”]
[form_element type=”textarea” validate=”” options=”” placeholder=”What sports or activities do you like to do? “]
[form_element type=”textarea” validate=”” options=”” placeholder=”If you are  returning to fitness how long has it been since you were physically active.”]
[form_element type=”textarea” validate=”” options=”” placeholder=”If you are new to fitness do you have any question you want answered?”]
[form_element type=”select” validate=”” options=”0, 1, 2, 3, 4, 5, 6, 7″ placeholder=”How many total days a week do you workout?”]
[form_element type=”select” validate=”” options=”0, 1, 2, 3, 4, 5, 6, 7″ placeholder=”How many days a week do you do strength training?”]
[form_element type=”select” validate=”” options=”0, 1, 2, 3, 4, 5, 6, 7″ placeholder=”How many days a week do you do flexibility training?”]
[form_element type=”select” validate=”” options=”0, 1, 2, 3, 4, 5, 6, 7″ placeholder=”How many days a week do you do cardiovascular training?”]
[form_element type=”textarea” validate=”” options=”” placeholder=”Do you have access to a gym or gym equipment? (If yes, which facility?) “]
[form_element type=”textarea” validate=”” options=”” placeholder=”Describe a meaningful task that you wish to improve. (climbing up stairs, run faster, do push-ups better, etc…”]
[form_element type=”textarea” validate=”” options=”” placeholder=”Do you have any fitness goals? (weight loss, run a marathon, post-natal recovery, etc…”]

Injuries and Pain

[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you have any current or past injuries/surgeries?”]
[form_element type=”textarea” validate=”” options=”” placeholder=”If so, please list: Year/Injury? “]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Was there an incident that brought your current on the problem? “]
[form_element type=”textarea” validate=”” options=”” placeholder=”If yes, please describe? “]
[form_element type=”select” validate=”” options=”0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10″ placeholder=”Please rate your level of pain over the last 24 hours on the pain scale below by marking an X on the line: 0 (no pain) and 10 (worst pain imaginable).”]
[form_element type=”select” validate=”” options=”occasionally, constant, getting better, getting worse” placeholder=”Please choose the words below that describes the state of your pain.”]
[form_element type=”select” validate=”” options=”worse in the morning, worse when trying to sleep, 24 hours a day” placeholder=”Please choose the words below that describes when your pain is worse.”]
[form_element type=”select” validate=”” options=”sitting, standing, exercise, rest” placeholder=”What makes your pain worse?”]
[form_element type=”select” validate=”” options=”sitting, standing, exercise, rest” placeholder=”What makes your pain better?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Are you pregnant?”]
[form_element type=”select” validate=”” options=”0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10+” placeholder=”How many live births have you had?”]
[form_element type=”textarea” validate=”” options=”” placeholder=”If yes, how where they delivered and did you have any complications? (vaginally, cesarean, forceps, etc.) “]
[form_element type=”select” validate=”” options=”balance problems, numbness in the face, pain with coughing or sneezing, dizziness, change in bladder or bowel function,numbness in the groin region, pelvic organ prolapse (POP)” placeholder=”Do you experience any of the following?”]
[form_element type=”textarea” validate=”” options=”” placeholder=”Please list and describe?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Have you had any investigative tests done for this injury (e.g. X-Ray, MRI, other)?”]
[form_element type=”textarea” validate=”” options=”” placeholder=”If yes, please describe? “]
[form_element type=”textarea” validate=”” options=”” placeholder=”Are you on any medications? If so please list:”]

Past Medical History. Please reply yes or no to all of the following conditions (information will remain confidential):

[form_element type=”select” validate=”” options=”yes, no” placeholder=”Heart disease”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Mental disorder”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Metal implants “]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Osteoporosis”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Steroids”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Diabetes”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Pace Maker”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Epilepsy”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Cancer”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Bleeding disorder”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Circulatory disorder”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Breathing disorder”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Hepatitis”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Circulatory disorder”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Hepatitis A, B, C”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Circulatory disorder”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”HIV/AIDS”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Other”]
[form_element type=”textarea” validate=”” options=”” placeholder=”If yes, please describe any of the above? “]

Hormonal Health

[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you have a bowel movement shortly after waking?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you get a surge of energy before bed?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you surfer from fatigue?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you often feel bloated?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you often feel moody or have PMS?”]
[form_element type=”select” validate=”” options=”yes, no” placeholder=”Do you feel foggy and have trouble concentrating?”]

Survey

[form_element type=”textarea” validate=”” options=”” placeholder=”How did you here about us? Can we thank anyone? “]

[form_element type=”select” validate=”required” options=”yes” placeholder=”I have read and agree to the Terms of Services”]
[form_element type=”select” validate=”required” options=”yes” placeholder=”I have read and agree to the Privacy Policy”]

[form_element type=”captcha” validate=”required” options=”” placeholder=”Add the 2 numbers to prove that you are human”] 

[form_element type=”submit” validate=”required” options=”” placeholder=”SUBMIT”] [/form]