FIT Personal Evaluation Intake FIT Personal Evaluation Intake Form Name Email Address Personal Evaluation and Goals What are your main reasons for taking Pilates/Gyrotonic? Increase flexibility Improve posture/alignment Strengthen/balance back and core muscles Incorporate into already existing workout program Replace existing workout ( ) Manage stress Just want to try it Other - Explain Below Other reasons for taking Pilates/Gyrotonic Explain your motivations(s) for joining the FIT program: What are the three main goals you hope to achieve with Pilates/Gyrotonic? What other health or physical goals would you like to achieve over the next 3 months? What long-term health or physical goals would you like to achieve over the next 12 months? Will this be the first time you have practiced Pilates/Gyrotonic? Y / N * Yes No If no, what types of sessions or classes have you attended in the past? What is your current flexibility/stretching routine? Daily After exercise only Once a week Infrequently What are your current sleeping habits? Less than 6 hours 6–8 hours 8+ hours Does your work or leisure activity involved any of the following for prolonged periods? Sitting Driving Bending Standing Lifting or moving heavy weights Other-Please explain below Other? Have you been told to only do physical activity recommended by a physician? * Yes No When you do physical activity, do you feel chest pain? * Yes No When not doing physical activity, have you had chest pain in the past month? * Yes No When not doing physical activity, have you had chest pain in the past month? * Yes No Do you ever lose your balance because of dizziness, or lose consciousness? * Yes No Is your blood pressure normal? * Yes No If you blood pressure is not normal, is it controlled with medication? * Yes No Do you have insulin dependent diabetes? * Yes No Have you ever been in a car accident resulting in trauma to the spine? * Yes No Do you have any other spinal or neck problems? * Yes No Do you have joint or bone problems that may be made worse by change in physical activity? * Yes No Does osteoporosis run in your family? * Yes No Do you have any lower back pain/problems or limited range of motion? * Yes No Does osteoporosis run in your family? * Yes No Do you have pelvic or hip pain? * Yes No Do you have any other reason you should not exercise or increased your physical activity? * Yes No Have you had major surgery within the past ten years? * Yes No Have you had minor surgery or sustained any injuries in the past two years? * Yes No Do you have pain or restricted movement in any other joins (knee, ankle, elbow, shoulder)? * Yes No Have you been diagnosed as hyper-mobile (excessive joint mobility)? * Yes No Are there any movements that cause you pain? If yes, please explain below. * Yes No Are you taking any medications that may affect your ability to exercise? * Yes No Are you currently being treated by a chiropractor? * Yes No Are you currently being treated by a physical therapist? * Yes No Are you currently being treated by an acupuncturist? * Yes No Do you suffer from asthma? * Yes No Do you suffer from epilepsy? If yes, is it controlled with medication? * Yes No Do you often get headaches? * Yes No Are you 65 years of age or older? * Yes No Are you pregnant? * Yes No Please provide any explanations needed for the above questions and list any health problems not already mentioned that may affect your ability to exercise: Please note that during this Pilates course, you will be expected to move from standing to lying. Would this be a problem for you? * Yes No Have you been referred to Pilates by a specialist practitioner? * Yes No Do you give permission for your instructor(s) to contact your referring practitioner? * Yes No Practitioner's Name/Phone (if applicable) Please advise us before beginning any session if, for any reason, your health or your ability to exercise changes (i.e., muscle soreness, joint pain, pulled muscles, minor injuries, etc.). If you feel unwell (dizziness, sickness, etc.), it would be prudent not to attend class. This is primarily for your safety and well-being, and also in consideration for the comfort, well-being, and health of others in the studio.Pilates exercises are very safe, but—as with all forms of physical exercise—it is wise to consult your doctor before starting Pilates sessions. It is not advisable to do Pilates between weeks 8–14 of pregnancy, unless by special arrangement with your instructor. You should also wait six weeks after delivery before resuming exercise.The sessions are not a substitute for medical counseling or treatment. If you have any doubts about the suitability of Pilates exercises, you should refer back to your medical practitioner. The instructors can accept no liability for personal injury related to participation in a session if your doctor has, on health grounds, advised against such exercise, or if you fail to observe instructions on safety and technique.You are responsible for your own body; listen to it and respect it. Your ability to perform exercises may vary from session to session depending on your state of well-being, fitness, tiredness, and/or stress level. Exercise should be performed at a pace that feels comfortable for you. Pain is the body’s warning system and should not be ignored. Please inform your instructor immediately if you feel any discomfort during a session. Please also inform the instructor if you felt any discomfort after a previous session. I understand that Fusion Pilates exercises involve hands-on (tactile) correction, and I hereby consent for my instructor to work in this way. * Agreed I confirm that I have read and understood the above advice, and that all of the information I have provided on this form is correct. * Agreed Signature Clear If you are human, leave this field blank.