Private Session Intake Form

Name

First Name

Last Name

Phone

(###)

###

####

How would you describe your current activity level?

Do you have any injuries, chronic conditions or medical concerns we should be aware of? (e.g., back pain, joint issues, recent injuries, any physical limitations or restrictions, etc)

Are you currently under the care of a healthcare provider or physical therapist?

What other form of exercises do you currently participate in? (i.e.: yoga, running, weightlifting, etc)

Do you have any specific goals or areas of focus you would like to address in your sessions?

Anything else you'd like us to know to help us create the best experience for you?

Release and Acknowledgement

I hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential. Core Revival Pilates has informed me that I am the responsible party for all the injuries during the session and incorrect information provided in this form. If any of my health, lifestyle or personal information/situation that may prevent my training has changed, I guarantee that I will inform the instructor immediately.

Checkbox

I consent