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(805) 768-4711

Movement/Medical History Questionnaire and Waiver

Please fill out and submit the form below

Contact Information

Name *

Birthdate *

Email *

Physical Address *

Do you wish to be included on our email list?
(We do not share this information with any other organization.)

Phone Numbers:


Best time to reach you:

In case of emergency, contact: *

How did you hear about us? *
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)

Medical History
Do you have any physical limitations or injuries that could be exacerbated with exercise?
YesNo
If so, please explain:

Have, or have had cardiovascular disease (i.e. heart problems)
YesNo

Have pain or pressure in the left or mid-chest areas, neck, left shoulder or arm
YesNo

Often feel faint or have spells of dizziness
YesNo

Experience extreme breathlessness after mild or medium exercise
YesNo

Have high blood pressure
YesNo

Smoke more than a pack of cigarettes a day
YesNo

Am over 60 years of age and am not accustomed to vigorous exercise
YesNo

Have bone/joint problems/osteoporosis that would be aggravated by exercise
YesNo

Have two or more of the following: family history of premature heart disease, obesity, type A behavior, stressful occupation, diabetes.
YesNo

Have a medical condition not mentioned here that might need special attention
YesNo

Taking medication that might cause adverse effects if combined with exercise
YesNo

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).

To 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 Address:

Health Care Provider's Phone:

Would you recommend this provider to other Body Solve It clients?
YesNo

Can we contact this person in reference to you?
YesNo

Lifestyle Information

Age: *

Occupation:

What is your current exercise program?



What is your movement history? (Include any physical activity or hobby such as hiking, biking, martial arts, etc. that you’ve done in the past.)

Have you had any experience with Pilates or Body rolling ? If so, when and for how long?

Please list 5 goals you have in regards to Pilates and/or physical fitness in general:




Studio Release Form *
I, , 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.

Refund and Cancellation Policy – Please read and initial the following details.

• There are no cash refunds for services, without exception. *
• Paid services may be transferred to immediate family members only. *
• All training packages expire 90 days from date of purchase and are non-refundable. *
• No holds or extensions are given on packages. *
• 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. *

Patron/User Signature: *

Today's Date *

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