Please answer questions fully & accurately to ensure you receive optimal instructions. Please indicate conditions you are experiencing or have experienced. This file is kept strictly confidential.

Date of Birth:

First Name:

Last Name:

Street Address:

City:

Province:

Postal Code:

Cell Phone:

Home Phone:

Work Phone:

Email Address:

Company:

Occupation / Title:

Do you wish to receive email notifications?:

How did you hear about Pilates Space?:

If applicable, include name of therapist who referred you:

Specify Number of Vaginal Deliveries:

Specify Number of C-Sections:

Do you smoke?:

Please indicate any health issues:
whiplashosteoporosissciaticaarthritisherniated discdiabetesasthmafibromyalgialow/high blood pressurescoliosisseizuresother

If other, please specify:

Please list any major accidents or operations:

Are you following a low calorie eating program? Please specify:

What are your hobbies and activities? What other types of exercises do you routinely participate in?

Have you had any past training in Pilates? If so, where and for how long?

What are your goals for participating in our program?

Please describe any areas of discomfort you have:

By filling out this form you are consenting to participate in the Pilates program conducted by Pilates Space. Learn More.