Personal History Form

Date

Name

Phone Number

Age

Do you have any Pilates Experience?

Do you have any Fitness or Pilates goals you’re working towards?

Do you have any Injuries or problems weight bearing through wrists or knees?

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EMERGENCY CONTACT

Name

Relationship

Contact number

Doctor/Midwife

Contact number

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FOR PREGNANT CLIENTS:

How Many Weeks Pregnant are you?

Estimated Due Date:

How many children have you had previously, and did you have any complications during or after those pregnancies?

Do you have any pain or discomfort?

Has your doctor given you any specific exercise limitations?

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FOR POST-NATAL CLIENTS:

How many weeks/months Post-natal are you?

Have you experienced any pain since you gave birth?

What type of birth did you have? Did you have any complications?

Have you been checked for a Diastasis Recti?

Did you have any injuries or pain during your pregnancy?

How many children do you have and how old are they?

Has your doctor/midwife cleared you to exercise?