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ABOUT
INSTRUCTORS
BOOK AN APPOINTMENT
PRICING
COMMUNITY
FRIENDS OF GOLD LINE
TESTIMONIALS
BEING SOCIAL
CONTACT
ABOUT
INSTRUCTORS
BOOK AN APPOINTMENT
PRICING
COMMUNITY
FRIENDS OF GOLD LINE
TESTIMONIALS
BEING SOCIAL
CONTACT
NEW CLIENT INTAKE FORM
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Date
*
Name
*
First
Last
Email
*
Phone Number
*
Address - Line 1
*
Address - Line 2
*
Emergency Contact
*
First
Last
Emergency Contact Phone
*
How did you hear about Gold Line Pilates?
What specific fitness or health goals do you hope to achieve through your practice?
What are your other activities? What keeps you active?
Have you done Pilates and/or GYROTONIC® before? Check all that apply.
*
Yes, I've done Pilates
Yes, I've done GYROTONIC®
I've never done either
Are you currently under a doctor's care?
*
Yes
No
If yes, please explain below:
Doctor's care Explanation
Are you currently engaging in other types of therapy? Check all that apply.
Physical Therapy
Chiropractic
Massage
Acupuncture/Acupressure
Reiki
Other
If you chose "Other", please explain below:
Other therapy:
Are you currently taking any medications?
*
Yes
No
If yes, please explain below:
Medication Explanation
Are you currently pregnant?
*
Yes
No
If yes, please let us know your due date below:
Pregnancy due date:
Have you given birth in the last 6 months?
*
Yes
No
Do you currently have, or have you previously had, any diagnosed back problems or spinal issues?
*
Yes
No
If yes, please explain below:
Back/Spinal Problem Explanation
Do you have any current injuries?
*
Yes
No
If yes, please explain below:
Current Injuries Explanation
Do you have any past injuries?
*
Yes
No
If yes, please explain below:
Past Injuries Explanation
Is there anything else that you would like your instructor to know about you, your body or your practice?
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