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:

Lose Weight

Strengthen Muscles

Stress Reduction

Mind/Body Connection

Balance

Work Target Area

Medical Reason

Other

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):

Head/Neck

Shoulder R/L

Elbow R/L

Hand R/L

Lower back

Middle back

Upper back

Rib cage

Abdomen

Pelvis

Hip R/L

SI Joint R/L

Knee R/L

Lower leg R/L

Foot/Ankle R/L

Present Physical Condition

Please describe your present physical condition:

Please list your primary fitness, sports, and recreational activities:

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

Special Conditions/Considerations:

Please list medications you are taking that might affect your participation in a program of exercise:

Please list any medical conditions that might affect your participation in a program of exercise (pregnancy, diabetes, high blood pressure, seizure disorder, MS, Parkinson’s, etc.)

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:

Please indicate that you understand that I require a 24-hour cancellation notice for private appointments. Failure to cancel within this time frame will result in you being charged the full fee for the appointment. Yes, I understand.

You agree that if you are recovering from an injury/illness that you have been given clearance to train from your doctor or physical therapist to participate in Pilates. Yes, I understand. No, I have not.

You agree, that you will keep KO Pilates informed prior to sessions of any changes to your health status. I agree

You understand that KO Pilates has the right to refuse service to clients that I feel undermine or endanger the positive culture of the studio. Yes, I agree

I agree to eliminate or reduce any distractions during virtual lessons as they can make workouts dangerous. Please make sure that you workout in a quiet space. If a distraction should occur, you agree to mute your feed during that time. Yes, I agree

Although we try to not change the schedule once it is posted, you understand and accept that KO Pilates produces the schedule and has the right to cancel and change session times. Yes, I agree

You understand that KO Pilates is dedicated to being present for the scheduled times, however, if sessions need to be cancelled due to the instructor illness or emergency, you understand that these periods may unfortunately occur. Yes, I agree.

Please let me know if you agree to have your image and likeness be captured and used in marketing and social media posts.. I agree to allow KO Pilates to capture my image for publication. I am not comfortable with KO Pilates capturing my image for publication.

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.