kelowna pilates,simply symmetria pilates & health


P : 250.878.1835 | E : | Hours: by appointment only

To get to know you a little better and discover how we can work with you to achieve your goals, please complete our New Client Form below.

1. Your Name (required)

2. Your Email (required)

3. Birthdate(required)

4. Occupation(required)

5. Street Address(required)

6. City(required)

7. Province(required)

8. Postal Code(required)

9. Home Phone(required)

10. Cell Phone(required)

11. Emergency Contact Phone (required)

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

Other: Please Specify

13. List all current, and any meaningful previous activities:
IE: Pilates, Aerobics, Skiing, Biking , Hiking, Running, Weight Lifting, Swimming, Climbing, Yoga, Walking, Dancing, Equestrian Riding, Golf etc.

14. Describe your present physical condition:
 Poor Fair Good Excellent Athlete

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

16. Other Injuries/Ailments:(required)

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.)

* Thank-you very much, you can now visit the Class Registration Page!

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