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Clinical Pilates New Client Form
Clinical Pilates Info Form
Your Details
Your Name:
*
First
Last
Date of Birth:
*
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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?
AHM
AIA Health Insurance
Australian Unity
Bupa
CBHS Health
CUA
Defence Health
GMHBA
GU Health
HBF
HCF
Health.com.au
Medibank
Navy Health
nib
Nurses & Midwives Health
Peoplecare Health Insurance
Police Health
St.Lukes Health
Teachers Health
Westfund Limited
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
DD slash MM slash YYYY
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