New Client Profile Name * First Name Last Name Email * Address * Street Address, City, State, Zip Date of Birth * Phone * (###) ### #### Are you able to receive text messages? * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### How did you hear about Pella Pilates? What types of exercise do you like to do? Occupation Check any and all that apply to you: Neck/Back Problems Knee Problems Shoulder Problems Hip Problems Heart Condition High/Low Blood Pressure Osteoporosis Stroke Dizzy Spells Asthma Seizures Arthritis Surgery Whiplash Fractures Prenatal/Postpartum Scoliosis Other When exercising, including climbing stairs, do you experience any of the following? Check all that apply. Chest pain Pressure over heart Shortness of breath Leg aches Tired out feeling Dizziness Other If you selected other, please describe: In this section, please describe any additional health concerns, history, medications, or other factors that could affect your work with me. What do you hope to achieve with pilates? Strengthen Core Posture Pain Management Sports Performance Balance Flexibility Other If you selected other, please describe: Height Weight (approximate) 24 HOUR CANCELLATION POLICY As a courtesy to others, I understand that if I cancel a scheduled appointment within less than 24 hours notice I will be held responsible for the appointment fee. Typing my name below acts as my signature. Pella Pilates & Wellness, LLC Waiver and Release * I hereby agree to participate in a pilates program upon the understanding and condition that I should stop exercising immediately if I detect discomfort of any sort during the course of my exercise program. I acknowledge upon starting an exercise program that I answered the above questions completely and honestly and reaffirm that I have consulted my personal physician and am physically capable of participating in such a program; I recognize the risks of illness and injury inherent in any exercise program and am participating in this program upon the agreement and understanding that I am hereby releasing the owner/instructor and the facility from any injuries, claims, costs, liabilities, or judgments arising out of my participation in this program or use of equipment/equipment machinery. Typing my name here acts as my signature. Today's Date MM DD YYYY Thank you! We will get in touch with you soon!