If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Today's Date * How did you hear about Seal Beach Pilates? Facebook Twitter Email Online Referral Word of Mouth Other If other, please describe. PERSONAL INFORMATION First Name * Last Name * Date of Birth * Address * Address 2 City * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Phone Height * Weight * EMERGENCY CONTACT INFORMATION Emergency Contact Name * Emergency Contact Phone Number * Relationship * MEDICAL HISTORY Are you currently under a physician's care? * Yes No Has a doctor advised you against exercise? * Yes No Do you have any of the following conditions? Anemia Asthma Heart Disease High Cholesterol Angina Diabetes Fibromyalgia Irregular Heart Beat Arthritis Epilepsy High Blood Pressure Other: please specify Please list any medications you are taking. * Have you sustained any of the following? Aneurysm Ankle/Foot Injury Arm/Elbow Injury Bone Fracture Clavicle/Shoulder Injury Hand/Wrist Injury Head/Neck Injury Heart Attack Hip/Pelvis Injury Knee/Thigh Injury Lower Back Injury Nerve Damage Respiratory Infection Stroke NA Others: (please specify) Please list any drug allergies you have: PHYSICAL FITNESS SUMMARY How would you describe your exercise habits? 1-2 times/week 3-4 times/week 5-7 times/week What would you like to achieve with us? Cardiovascular Conditioning Flexibility General Conditioning Muscular Growth Weight Loss Other
Do you have any of the following conditions?
Have you sustained any of the following?
