Clinical Pilates Info Form

Your Details

Your Name:*

First Last

Date of Birth:*

Email Address:*

Contact Number:

Address:

Street Address Suburb Post Code

Hidden

Emergency Contact Name:

Hidden

Emergency Contact Phone:

Hidden

Emergency Contact Relationship: (i.e. partner / parent, sibling, friend, ect)

GP Details and Private Health Insurance

GP Doctors Name:

GP Clinic Name:

Do you have Private Health Insurance?*

No
Yes

Does your Private Health Cover include extras?

No
Yes
Not Sure

Which Private Health Insurer are you currently with?

Your Pilates Goals

The more information we have only helps us create the best program for you and your goals.

Are You Currently Pregnant or Recently Gave Birth?*

No
Yes

Are You Prenatal or Postnatal?

Prenatal / Pregnancy
Postnatal

Baby's Name

Baby's Date of Birth

What is your current Due Date?

Have you had any previous pregnancies?

No
Yes

How many children do you have? (Any multiple pregnancies?)

What is your reason for starting Clinical Pilates with MVFIT?

What do you wish to work on during your Clincial Pilates sessions?

Do you have Clinical Pilates experience?*

No - I've never done pilates before
Yes - I've done some form of pilates before

Please provide further details on what pilates you have done in the past (i.e. have you done machine based pilates, when was your last pilates session, how long did you do pilates for previously...)

Are you currently training for anything in particular? i.e. a half marathon, play a team sport, weight loss, post-partum..*

No
Yes

Please give a brief description of what you are training for? i.e. a half marathon, play a team sport, weight loss, post-partum..

Do you currently do any other form of exercise?*

No
Yes

What other exercise are you currently doing?

Do you have any current medical concerns or injuries?*

No
Yes

Please give a brief description of any of your current medical concerns or injuries?

Do you have any relevant past medical concerns/injuries we should be aware of?*

No
Yes

Please list any relevant past medical concerns/injuries.

Are you currently taking any regular medications?*

No
Yes

Please list below the current medications you are taking.

Anything else you wish to share with your Clinical Pilates team before starting...

Thank you for completing our Clinical Pilates Client Form

Clinical Pilates New Client Form

Clinical Pilates Info Form

Your Details

GP Details and Private Health Insurance

Your Pilates Goals