Let Us Get To Know You

All sessions with Jessmo Pilates are completely personalized to you. We like to get to know you and some information about your body before we begin. It helps us maximize the time we have together. This form is not HIPPA protected so please provide as much information as you are comfortable sharing. If there is something you would rather share in person, please just say that in the text field.

Name

First Name

Last Name

Phone

(###)

###

####

Email you used to request sessions and purchase packages.

Birthday

YYYY

Emergency Contact, Name, and Phone Number

Do you have experience with Pilates?

yes

If Yes, please explain.

Let me know what you've tried, for how long, how recently, and what was positive or negative about your prior experience.

Health History

Do you have any medical problems, conditions, orthopedic injuries or specific areas of pain? If yes, please explain. (spinal condition, osteoporosis, arthritis, joint replacement, MS, etc.)

Please list any surgeries.

Are you pregnant, recently pregnant or trying to become pregnant?

If you are pregnant or postpartum, please indicate your timeline.

What exercise, if any, do you currently do? How often?

How would you describe your current fitness level and general health?

Do you play any sports or have a serious athletic history? Are you currently a professional Athlete?

What are you hoping to achieve with Pilates? What are your interests and goals?

Can be anything from having an hour of focused movement and meditative flow, to cross-training, to building core strength to dealing with an injury or just genral fitness routine.

Is there anything else you would like us to know about you?

Did someone refer you to Jessmo Pilates? If yes, tell us who!