1. Your Name (required)

2. Your Email (required)

3. Birthdate

4. Occupation

5. Street Address

6. City

7. Province

8. Postal Code

9. Home Phone(required)

10. Cell Phone

11. Emergency Contact Phone (required)

12. What specific fitness or health goals do you hope to achieve through the Pilates Method?
 Lose Weight Strengthen Muscles Stress Reduction Mind Body Connection Blance Work Specific Area Medical Reason

Other: Please Specify

15. Describe your physical history: Injuries/Surgeries, Ailments/Illnesses, Pregnancies:

16. Other Injuries/Ailments:

Which areas of your body were affected (R) or (L):
 Head Arm Hand Lower Back Hip Pelvis Neck Upper Back Ribs Knee Shoulder Mid Back Abdomen Ankle/Foot Other

17. Other comments / Questions?

18. How did you hear about Simply Symmetria Pilates & Health?
If applicable please include the name of the person who referred you.
(friends, doctors, physiotherapist etc.)
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