Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
How did you hear about Radiant Pilates Northwest
Friend
Online Search
Sandwich Board
Flyer or Postcard
What is your occupation? What are your hobbies?
What is your height and approximate weight?
Which hand is dominant?
Right
Left
Ambidextrous
Have you done Pilates?
Yes, only mat
Yes, all of it all the time!
No
Have you used the Melt method before?
Yes, all the time!
Yes
Once years ago
No
Do you suffer from chronic pain?
Yes
No
Describe any pain or dysfunction present in your body today, as well as the approximate date of onset. Include if and when you have seen a practitioner for the listed issues and if a diagnosis was given.
What makes your issues better? Worse? Please indicate which issue you are referring to.
Please list all surgeries and years or approximates.
Have you had any orthopedic injuries? If yes, please list which parts of the body and year.
How many days a week are you active?
1 - 2
3 - 4
5 - 6
I never stop
I have kids, but I try
What physical activities do you enjoy doing?
Are you pregnant?
Yes
No
If yes, when is your due date? Any complications or high risk factors?
Have you experienced any of the below?
What are your short and long term fitness goals?
Is there anything else you'd like to tell me?
