Pilates Intake Form

First Name

Last Name


Cell Phone

Date of Birth


Have you practiced Pilates in the past? If so, which type of Pilates (Mat or Apparatus)?

What are your health and fitness goals? What do you hope to accomplish with Pilates?

Do you currently exercise? If so, how often? Please describe your average workout week and what type of movement you do.

Do you have any past or present injuries? If yes, please explain.

Do you have any chronic injuries or pain from any sport or activity that should be taken into consideration in developing your plan?

Are you under the care of a physician, chiropractor, or other health care professional for any reason? Please explain.

Have you been hospitalized or had any surgeries in the last 6 months? If yes, please explain.

Pilates instructors commonly give hands-on adjustments and tactile feedback to help you find your proper alignment and muscle recruitment. You’re always welcome to decline a hands-on adjustment at any time. Are you comfortable with hands-on adjustments?

Are you currently pregnant, or have you given birth within the last 8 weeks? If yes, please list your due date:

Check all that apply:

  • Anemia
  • Asthma
  • Diabetes
  • Heart Disease
  • Heart Murmur
  • Heart Surgery
  • Hypertension
  • Pulmonary Disease
  • Stress Fracture
  • Thyroid Problems
  • Wheezing
  • Vertigo

Other Conditions:

24 Hour Cancellation Policy

I understand that if I must cancel a scheduled appointment or class, I will notify the Concierge Desk by calling 360-352-3400 24 hours in advance or I will be held responsible for payment. The instructor will work hard to stay on schedule. We respect and honor your time and we ask you to do the same.

I have read and understand the above


Please sign to state that you read and understand the policy

I understand that the Pilates work I receive is provided for the purposes of, including but not limited to, improving my fitness, relaxation, stress reduction, relief of muscular tension, and/or balancing potential misalignments of the body. If I experience any pain or discomfort during the session(s), I will immediately inform the instructor so that the effort and/or exercise may be adjusted to my level of comfort. I understand that if I feel discomfort and/or pain, I will stop and inform the instructor. I understand that a medical evaluation is advisable before beginning any program of physical conditioning or exercise, and that it is my responsibility to do so. I have or will continue to keep the instructor informed of any physical condition or disability, which would prevent or limit my participation in an exercise, physical conditioning, and/or body work. I acknowledge that, although the Pilates I participate in may have substantial physical benefits, the instructor is not engaged in diagnosing or treating medical diseases or any other medical conditions, nor do sessions serve as a substitute for medical diagnosis or treatment when such attention is needed. Because Pilates is contraindicated (should not be done) under certain medical conditions, I affirm that I have stated all my known medical conditions accurately and answered all questions honestly. I agree to keep the instructor updated to any changes in my medical profile and understand that there shall be no liability on the practitioner’s or facility’s part should I forget to do so. I expressly assume all risks of participation in Pilates. I recognize that though many positive changes can occur as a result of Pilates, there is the possibility of negative side effects including possible short-term aggravation of some symptoms. I affirm that I am at least 18 years of age or have the permission of a consenting parent/guardian.

Please check all consent and disclosure checkboxes.

Your form has been successfully submitted. Thank you!

Adult Signature:

Sign for Child: