Intake Form

First name

Last name

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Emergency contact name and phone number

Occupation

What are your goals for attending NeuroMotion Studio sessions?

Do you have any hobbies or activities you really enjoy?

Are there any activities you do not enjoy, aggravate symptoms or you try to avoid?

Short anHave you seen or are you currently seeing another health/movement professional(s)? Please explain the type of professional, the reason and recommended treatment plan.

Do you experience any of the following?

Headaches or Jaw pain (clenching, grinding, TMJ)

Neck Pain

Shoulder Pain

Hearing concerns

Vison Concerns - wear glasses or contacts

Carpel tunnel, Tennis Elbow or hand numbness

Spasticity

Pelvic Pain

Hip Pain

Back Pain

Pelvic Health concerns

Balance concerns or Dizziness

Leg or Knee pain

Ankle or Foot Pain

Hypermobility

Brain Fog or poor memory or cognitive concerns

Poor co-ordination

Fatigue

Trouble sleeping

Dry mouth

Dry eyes

Digestive concerns/nausea

Spasticity

Shortness of breath or poor endurance

Mental Health concerns

If you answered "yes" to any of the above, please share more details.

Are there any positions you are not comfortable working in? For example, laying on the floor, working on hands and knees, standing work.

Do you suffer from any other weaknesses, concerns, aches, pains or limited mobility or health concerns? If yes please explain.

In the space provided, please list any injuries, scars, tattoos, surgeries, falls or accidents you have experienced.

On a scale of 1 - 10 how would you rate your daily stress level?

Is there anything else you would like to add?

Are you pregnant?

Yes

No

If you answered "yes" to the above question, please share any symptoms or concerns you are having with this pregnancy.

Participant Release of Liability and Knowledge of Agreement

I understand that participation in any physical activity or exercise session includes risks. I assume any risk of injury which might occur due to participation in this/these exercise session(s). I confirm I have not been advised by a doctor to avoid physical activity. I release Jennifer Szwedo from all liability, costs and damages which might occur from participation in these sessions.

I understand I am not obligated to perform any movements or exercises I am not comfortable performing. If I feel unsafe or uncomfortable at any point during my training session it is my responsibility to inform the instructor

I understand results of any fitness or wellness program cannot be guaranteed and my progress is dependent on my effort and cooperation outside and during training sessions.

I give Jennie Szwedo permission to send me emails regarding upcoming Pilates classes or promotions

I understand that if attending a workshop the information provided will be for educational purposes and not meant to replace medical advice.

I understand there is a 24 hour cancellation policy which includes the start of a group session. If I cancel less then 24 hours before my scheduled session, I may not be refunded. I also acknowledge that if I arrive late to a session, I may not receive the entire time I paid for.