"*" indicates required fields Name* Email* Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation Employer Legal Guardian (if Applicable) Legal Guardian PhoneEmergency Contact Name* Emergency Contact Phone*Name of referring professional / Or name of person Kathleen can thank (if applicable): Please check how you heard about Kathleen Talk or Workshop She Gave Web Search Other How did you hear about Kathleen (other) Policies & ConsentCancellation Policy Your appointment time is reserved just for you. A late cancellation or a missed session leaves a hole in Kathleen’s day that could have been filled by another client. As such, she requires at least 24 hours’ notice for any cancellations or changes to your appointment. Clients who provide less than 24 hours’ notice, or miss their appointment, will be charged a cancellation fee equal to the cost of the cancelled appointment. I am aware of, and I agree to the above Cancellation Policy. Signature*Consent to Be In The Keller Method Vitality Database KMV deeply respects your privacy. Your address will never be shared. KMV only would communicate with you professionally about you and your sessions, KMV business updates that apply to you and pertinent information that may directly interest or help you specifically. I agree to be in KMV database* Yes No ActivitiesHave you ever taken Pilates or learned Self Myofascial Release before? Indicate when and with whom.*In which activities and sports do you currently engage? State how frequently.*If you have an occupation, what do you do? Are you currently working?*What are the physical requirements of your occupation, volunteer or personal interest activities? (e.g. sitting, computer work, standing, bending, lifting)*What are your fitness or health goals through participation in Pilates or SMR?*Health HistoryHave you ever had a major illness, accident or surgery? If yes, please briefly explain.Ongoing therapies (e.g. physio, chiropractic, massage) and indicate practitioner(s)’ name(s).Check currently relevant or relevant to your history. Please provide specific details if necessary.Arthritis (i.e. Osteoarthritis, Rheumatoid Arthritis): Arthritis (i.e. Osteoarthritis, Rheumatoid Arthritis) Arthritis DetailsCancer Cancer Cancer DetailsCarpal Tunnel Syndrome Carpal Tunnel Syndrome Carpal Tunnel DetailsChronic Fatigue Syndrome Chronic Fatigue Syndrome Chronic Fatigue DetailsConcussion Concussion Concussion DetailsDigestive Issues Digestive Issues Digestive Issue DetailsFibromyalgia Fibromyalgia Fibromyalgia DetailsHeadaches: (e.g migraine, tension) Headaches: (e.g migraine, tension) Headache DetailsInsomnia / Sleep issues Insomnia / Sleep issues Insomnia DetailsJoint problems (indicate joints, hypermobility, repetitive strain injury) Joint problems (indicate joints, hypermobility, repetitive strain injury) Joint Problem DetailsNeurological Conditions: (e.g. MS, Parkinson’s, Stroke) Neurological Conditions: (e.g. MS, Parkinson’s, Stroke) Neurological Conditions DetailsOsteoporosis Osteoporosis Osteoporosis DetailsSpinal Conditions: (disc issues, sciatica, spinal fusion, spinal stenosis, spondylolisthesis) Spinal Conditions: (disc issues, sciatica, spinal fusion, spinal stenosis, spondylolisthesis) Spinal Condition DetailsSystemic conditions: (high blood pressure, diabetes, lung or breathing issues) Systemic conditions: (high blood pressure, diabetes, lung or breathing issues) Systemic Condition DetailsThoracic Outlet Syndrome Thoracic Outlet Syndrome Thoracic Outlet Syndrome DetailsIs there anything else not covered in this form that you want Kathleen to know?EmailThis field is for validation purposes and should be left unchanged.