Health History ℹ Basic Information👨🦲 Name* First Last 👶 Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 📱 Phone📧 Email 👷♀️ Occupation ⚠ Emergency Contact InformationContact Name First Last PhoneEmail ❤ Detailed Health InformationPlease indicate whether you experience or have experienced any of the following: Arthritis Asthma Cancer Chest Pain Diabetes Fibromyalgia Headaches Heart Disease High Cholesterol Hypertension Child Birth Metabolic Disorder Neurological Disorder Osteoporosis Spinal Disorder Describe any current/past injuries, surgeries, pregnancies, significant medical or alternative treatments. Check all body parts involved. Specify right(R) left(L) or both(B)Describe your present physical condition, including any medications:Please check which of the following forms of care, if any, you are receiving: Physical Therapy Chiropractic Massage Acupuncture Other You selected, "Other" – please explain that form of care:List current physical activities (including sports, exercise, movement and martial arts):What brings you to Tonya Herrick Pilates? What are your goals?How did you hear about us?🖊 SignatureI certify this information is correct to the best of my knowledge.* First Last Agreement Date* MM slash DD slash YYYY ❌ Cancellation PolicyAs a courtesy to other clients, I understand that if I need to cancel a scheduled session, I will make every effort to notify Tonya Herrick Pilates LLC at least 24 hours in advance. Late or same day cancellations will be charged to class card or package.🖊 SignatureI agree to the cancellation policy.* First Last Cancellation Policy Agreement Date* MM slash DD slash YYYY Tonya Herrick Pilates LLC Release I hereby certify that I am voluntarily participating in a physical conditioning and corrective exercise program with Tonya Herrick Pilates. I hereby affirm that I have my physician’s approval, I am in good physical condition, and I do not suffer from any disability that would limit or prevent my participation in this program. After having had the opportunity to inquire in detail regarding all aspects of the program and to have had all questions with regard to the program satisfactorily answered, including any physiological and/or psychological changes which can occur, I certify that I understand the potential risks of the program. I agree to release from all liability and to indemnify Tonya Herrick Pilates LLC/Tonya Herrick, its officers, employees and all representatives from and against all claims, actions, judgments, costs, expenses, and demands with respect to injury, loss, death or damage to my person or property in connection with my taking part in the above-stated program. It is understood and agreed that this agreement is to be binding on myself, my heirs, executors, administrators and assigns. I certify that I have read and understood the above. Intending to be legally bound, I hereby make this agreement on:* MM slash DD slash YYYY 🖊 SignatureI agree to the above release.* First Last Δ
