Movement/Medical History Questionnaire and Waiver Please fill out and submit the form below Your DetailsName:* First Last Birthdate:* MM slash DD slash YYYY Email* Mailing 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 Do you wish to be included on our email list?*(We do not share this information with any other organization.) Yes, include me No, don't email me What's the best time to reach you? Cell / Mobile:*Home:WorkIn case of emergency, contact:* How did you hear about Body Solve It?* Newspaper ad (if so, please specify below) Trainer/Client referral (if so, please specify below) Doctor/Health Professional (if so, please specify below) Other (if so, please specify below) Specify where you heard about Body Solve It: Medical HistoryDo you have any physical limitations or injuries that could be exacerbated with exercise?* Yes No Please explain your physical limitations or injuries: Do you have, or have you ever had cardiovascular disease (i.e. heart problems)* Yes No Do you have pain or pressure in the left or mid-chest areas, neck, left shoulder or arm?* Yes No Do you often feel faint or have spells of dizziness?* Yes No Do you experience extreme breathlessness after mild or medium exercise?* Yes No Do you have high blood pressure?* Yes No Do you smoke more than a pack of cigarettes a day?* Yes No Are you over 60 years of age and not accustomed to vigorous exercise?* Yes No Do you have bone/joint problems/osteoporosis that would be aggravated by exercise?* Yes No Do you have two or more of the following conditions:*• Family history of premature heart disease • Obesity • Type A behavior • Stressful occupation • Diabetes Yes, two or more of these No Do you have a medical condition not mentioned here that might need special attention?* Yes No Are you taking medication that might cause adverse effects if combined with exercise?* Yes No If you answered yes to any of the previous questions ...Please specify below (ie. spinal injuries, arthritis, osteoporosis etc. along with location, date diagnosed and so forth)Medical CareTo better help us tailor your Pilates workouts please let us know if you have seen a health care provider (osteopath, physical therapist, chiropractor, acupuncturist, body worker i.e. Feldenkrais, Rolfing, massage etc.) for any specific issues or injuries.Health Care Provider's Name: Seeing him/her for how long? Health Care Provider's Phone: Health Care Provider's Address: Would you recommend this provider to other Body Solve It clients?* Yes No Can we contact this person in reference to you?* Yes No Lifestyle InformationYour age:*Your occupation: What is your current exercise program?Try to list the activity you do, the frequency and the approximate date you began this programWhat is your movement history?Include any physical activity or hobby such as hiking, biking, martial arts, etc. that you’ve done in the past.List 5 goals you have in regards to Pilates and/or physical fitness in general:*List one goal on each line.Have you had any experience with Pilates or Body Rolling?If so, when, and for how long?Studio PoliciesStudio Release Consent* I, the aforementioned, as consideration for my participation in the fitness activities of Body Solve It, legally bind myself and my heirs, executors and administrators, and hereby waive fully and finally any causes of action or claims against Body Solve It and forever release Body Solve It along with its owners, directors, officers, employees, members, shareholders, representatives, agents and assignees from any and all liability, responsibility, claims, causes of action, injuries, judgments or other damage of any nature whatsoever, including, but not limited to any personal injury incurred by the undersigned patron, user/subscriber/member of Body Solve It directly or indirectly resulting from participation in the services and/or activities undertaken at Body Solve It as well as any personal injury sustained by the undersigned patron’s presence on the real property premises of Body Solve It whether or not participating in or utilizing the services and/or/ activities of Body Solve It.There are no cash refunds for services, without exception.*Please initial below if you agree: Paid services may be transferred to immediate family members only.*Please initial below if you agree: All training packages expire 90 days from date of purchase and are non-refundable.*Please initial below if you agree: No holds or extensions are given on packages.*Please initial below if you agree: Body Solve It has a 24 hour cancellation policy. If I am unable to come to a scheduled appointment for any reason, I must contact the studio at least 24 hours in advance or the full session fee will be charged.*Please initial below if you agree: Patron / User Signature:* Enter Full NameToday's Date:* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.