Pilates Assessment Form
Personal Information
Full Name
Email
Phone Number
Date of Birth
Height (cm)
Weight (kg)
BMI (Body Mass Index)
Occupation
Health History
Do you have any medical conditions?
Are you currently taking any medications?
Have you had any surgeries or injuries?
Yes
No
If yes, please provide details:
Do you experience any pain?
Neck
Shoulders
Back
Hips
Knees
Ankles/Feet
Other
If you experience pain, please describe:
Fitness Background
Current Activity Level
Select an option
Sedentary (little to no exercise)
Light (1-3 days per week)
Moderate (3-5 days per week)
Active (6-7 days per week)
Very Active (twice daily)
Current Physical Activities
Have you practiced Pilates before?
Yes
No
If yes, please provide details:
Pilates Goals
What are your goals for Pilates? (Check all that apply)
Increase strength
Improve flexibility
Better posture
Enhance balance and coordination
Strengthen core
Rehabilitation from injury
Stress reduction
Other
Please describe your specific goals:
Preferred Schedule
Select an option
Weekday Mornings
Weekday Afternoons
Weekday Evenings
Weekend Mornings
Weekend Afternoons
How many sessions per week would you like?
Select an option
1 session per week
2 sessions per week
3 sessions per week
4 or more sessions per week
Lifestyle & Health Assessment
Daily Activity Levels
Inactive Rarely engages in physical activity or exercise.
Casually Active Light exercise or movement, (1-3 times per week.)
Moderately Active: Regular exercise sessions, about (3-5 times per week.)
Highly Active: Vigorous activity or workouts, almost daily (6-7 times per week.)
Stress Level
Low
Medium
High
Sleep Quality
Select your typical sleep quality
Excellent (7-9 hours, wake up refreshed)
Good (6-7 hours, generally rested)
Fair (5-6 hours, sometimes tired)
Poor (Less than 5 hours or irregular)
Nutrition Habits
Regular meal schedule
Balanced diet with proteins and vegetables
Adequate water intake (8+ glasses/day)
Take supplements/vitamins
Energy Levels Throughout the Day
Select your typical energy pattern
Consistent energy throughout the day
Highest energy in the morning
Afternoon energy dip
More energetic in the evening
Additional Information
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