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Registration Form

Health Questionnaire

Please answer the following questions. All information is confidential and will only be used to help your instructor create a personalized program for you.

What specific health or fitness goals would you like to achieve:

Physical History

Please note pre-existing conditions, including prior accidents, injuries, surgeries, or medical treatments that involve the following (date of onset/duration/severity/location):

Present Physical Condition

Please note any current injuries or areas of concern on the figures below.

Special Conditions/Considerations:

Are you currently seeing a health care practitioner (ND, MD, DC, DO, PT, etc.) for any of these conditions? If yes, has your practitioner/therapist given you any activity restrictions?
If yes, please list:
If you would like us to be in touch with your health care practitioner, please provide us with her/his contact information:
Upon submitting this form, you acknowledge that by entering your name below that the above details are true and correct.
Thank you and welcome to KO Pilates! We will be in touch with you shortly to answer any questions you may have and book your Private Session.