Intake Form | radiantlife

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New Client Intake Pilates/Yoga

For Questions, email:

RadiantKeri@outlook.com

First Name

Phone

Last Name

Email

Address

Birthday

Emergency Contact Name & Number

List Any Allergies

List Previous Pilates or Yoga Experience

Current or Previous Medical Conditions, Injuries, Surgeries, etc.

Current Medications

Are you pregnant or attempting to become pregnant?

What is your current fitness routine?

What are your goals in practicing pilates or yoga?

Overall how do you feel physically & emotionally/mentally?

Any areas of discomfort or pain? Describe

Areas of stress in your life?

Areas you would like to focus on?

Are you comfortable with hands on assists?

Is there anything else you feel I should know?

Today's Date

Thanks for submitting!

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