Have you had prior experience with Pilates?

Yes

No

Do you have any medical conditions or injuries that may affect your ability to fully participate in a Pilates fitness program?

Yes

No

In the past 3 months, have you had or do you experience:

A general change in health

Diffiuclty swallowing

shortness of breath

infection

fevers/chills/sweats

numbness or tingling

changes in appetite

changes in bowel/bladder function

dizziness

nausea/vomiting

unexplained weight change

Past Medical History: Have you ever been told you have:

Allergies

Anemia

Arthritis or Arthritic Condition

Asthma

Autoimmune disease

Cancer

Diabetes

Depression

Eating Disorder

Heart Problems

high blood pressure

Joint replacement

Osteoporosis

Osteopenia

Peripheral Vascular Disease

Pacemaker

Prostate Problems

Shortness of Breath

Stroke

Vertigo

Please check any of the following providers whose care you are currently under.

Physical Therapist

Chiropractor

Personal Trainer

Nutritionist

Massage Therapist

Physician

If needed to improve your class experience here at CONNECT do you give permission for us to contact your other providers to better understand any special needs you may have?

Yes

No