DBP Client Registration Form
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First Name *
Last Name *
Date of Birth
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Email Address
Cell Phone
Emergency Contact
Emergency Contact Number
Occupation
Hobbies and interests
What parts of your body do you feel are strong?
What kinds of movements give you most pleasure, e.g. walking, running, jumping, dancing, swimming, doing a particular sport etc.?
Exercise Activity
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List type of activity or exercise
Do you have any experience with Pilates? If yes, please describe
Are you currently receiving professional healthcare, e.g. medical, chiropractic, physical therapy? If yes, please describe.
Are you currently experiencing any physical ailments, e.g. joint pain, back pain, muscle pain, a specific condition? If yes, please explain.
Are you currently pregnant?
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If yes, how many months?
Have you ever been treated for any of the following conditions? (check all that apply)
Have you been tested for osteoporosis?
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Have you been diagnosed with osteoporosis/osteopenia?
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Have you had any joint replacement surgeries, e.g. hip, knee, shoulder? If yes, please specify.
Have you had any surgeries in the last 4 months? If yes, please describe.
Have you had any severe episodes of back pain in the last 12 months?
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If yes, how many episodes have you experienced in the last 12 months?
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Is there anything not covered in previous questions you would like to add?
Release and Waiver Agreement
My registration for and participation in Deep Breath Pilates ("DBP") online classes means that I acknowledge Pilates and related movement activities are potentially strenuous physical activities. I absolve Chris Evans, and DBP from responsibility for any injuries sustained while engaging in these movement activities. I hereby release on behalf of myself, my heirs and assigns, Chris Evans and DBP, from any claims, demands and causes of actions arising from my participation in any DBP exercise programs. This Release and Waiver Agreement will be in effect for all asessions, classes, and workshops via Skype, Zoom or any other video conferencing tool from this date forward. *
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Please sign the Release and Waiver agreement by completing your full name below *
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