Student Intake A movement & health history questionnaire to help me create a focused and satisfying session for you. Please feel free to contact me directly before your session if there's anything else you'd like to share: email@example.com Looking forward to working with you soon! Name* First Last Email* Birthdate*Health + Wellness HistoryPlease select all that apply.* Have, or have had cardiovascular disease (i.e. heart problems) Have pain or pressure in the left or mid-chest areas, neck, left shoulder or arm Often feel faint or have spells of dizziness Experience extreme breathlessness after mild or medium exercise Have high blood pressure Smoke more than a pack of cigarettes a day Are over 60 years of age and am not accustomed to vigorous exercise Have bone/joint problems/osteoporosis that would be aggravated by exercise Have two or more of the following: family history of premature heart disease, obesity, type A behavior, stressful occupation, diabetes Have a medical condition not mentioned here that might need special attention Taking medication that might cause adverse effects if combined with exercise None of the above Further ExplanationsIf 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).Lifestyle + Movement HistoryOccupation/VocationCurrent Movement Practice*Please describe what physical activities you typically engage in and how often. Also, let me know what types of exercise/movement you LOVE most.Movement Practice Past*What kinds of movement have you done? Include sports, hobbies, movement or physicality related to work and play. What would you LOVE to be able to do again? How long have you been practicing Pilates?*What are your current exercise/movement goals?*Please share at least 1 short-term goal (to achieve in the next 1-3 months) and 1 long-term goal (to achieve in the next 6-12 months).What would you like to focus on in your session?*Consider areas of the body you'd like to explore/learn more about; exercises you'd like to explore; pain, limitations, or injuries you'd like to troubleshoot.