Intake Form Name* First Last Email* Phone* Age*Date of Birth* Month Day Year Sex Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status Emergency Contact Name* First Last Second Emergency Contact Name First Last Emergency Contact Relationship* Second Emergency Contact Relationship Emergency Contact Phone*Second Emergency Contact PhoneHealth History*Please check all that apply Diabetes High Blood Pressure Heart Disease/Condition (Specify Below) Lung Disease/Condition (Specify Below) Seizures (Specify Below) Autoimmune Disease (Specify Below) Known Blood Clots (Specify Below) Osteopenia/Osteporosis (Specify T Score Below) Other (Specify Below) None Specify HereHealth History 2*Please check all that apply Arthritis Chronic Fatigue Syndrome Fibromyalgia Gastric Reflux Glaucoma Incontinence Multiple Sclerosis Peripheral Neuropathy None Orthopedic/Joint Problems*Please check all that apply Anterior Cruciate Ligament Knee Injuries Facet Joint Syndrome Herniated or Bulging Disc Rheumatoid Arthritis Spondylolisthesis Stenosis Scoliosis Sciatica Total Hip Replacement Other None Other Prior Injuries, Musculoskeletal and Neuromuscular Issues*Please check all that apply Adhesive Capulitis (Frozen Shoulder) Carpal Tunnel Syndrome Plantar Fascitis Rotator Cuff Impingement Thoracic Outlet Syndrome Other None Other Medications you are presently taking:*(Put N/A if not applicable)Allergies (including Medications)Date of last complete physical examination MM slash DD slash YYYY Physical Exam ResultsNormalAbnormalNever Had OneCan't RememberAre You Pregnant? Yes No Have you had any prior deliveries? Please list any prior surgeries, medical or diagnostic tests you have had in the past two years:*(Put N/A if not applicable)How Physically fit do you feel? Below Average Average Above Average Are you currently involved in an exercise program? Yes No Please describe your exercise routine:How did you hear about Pure Pilates?* Pure Pilates Client (Please Specify) Sponsored Event (Please Specify) Staff Referral (Please Specify) Professional Drop-in Internet/Website Community Auction/Raffle Winner Email/Newsletter Other Specify Here Liability WaiverRelease of Liability I understand that by participating in physical exercise or training activities, virtually or in-person, I am doing so entirely at my own risk and that I assume all risks of injury, illness, or death. On behalf of myself, my heirs, and personal representatives, I hereby release Pure Pilates NJ, LLC, Carol Crincoli, and all employees, agents, representatives, and independent contractors from all claims, liabilities, or demands of any kind on account of any personal injury (including death), property damage or other damages arising out of or because of participation of all activities. I am signing this Release of Liability freely and voluntarily. Declaration of fitness to participate I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment except as hereinafter stated. I have had a physical examination by a licensed physician within the past six (6) months confirming that I have no cardiovascular ailment or other physical disability that would prevent me from engaging in a strength, flexibility, and aerobic exercise program. Privacy Policy: Privacy Policy for Pure Pilates Clients: Once you create a log-in or become a client of Pure Pilates, you will be added to our newsletter mailing list and will receive updates, offers, and notifications from the studio powered by Active Campaign. You can unsubscribe at any time. Pure Pilates and the online services we use, DO NOT share your personal information with any third parties.* I have read and agree to the Liability Waiver
