Medical Release Form

Have you ever been treated by a physician for:

Other:

Are you pregnant?

Yes

No

Prior Deliveries

Prior Surgeries:

Prior Injuries, Musculoskeletal and Neuromuscular Issues:

Adhesive Capsulitis (frozen shoulder)

Carpal Tunnel Syndrome

Thoracic Outlet Syndrome

Rotator Cuff Impingement

Plantar Fasciitis

Other:

Are you currently taking medications and/or nutritional supplements?

Yes

No

If so, please list the medications and/or nutritional supplements you are taking:

Activity Level/Exercise Frequency

Prior Movement Experience (dance, yoga, etc.)

Name *

Date *

Email *

Medical Release Form for Pilates Private/Duet clients