* 1. General personal information:

* 3. Additional information:

* 4. Please indicate the symptoms or physical problems that you are currently experiencing or have experienced in the past.

  Yes No N/A
Allergies
Arthritis
Headaches
Dizziness
Respiratory/Lungs
Sciatic
Weakness in arms or legs
Insomnia
Hearing
Fatigue
Cardiovascular/Heart
High/Low Blood Pressure
Numbness
Vision/Contacts
Scoliosis
Poor Memory
Indigestion
Epilepsy

* 5. Here at Bodymap Pilates we would like to help meet your personal goals. We need a little more information about you so that we can best design a package that will fit your lifestyle and help you to achieve these goals. Have you been to a Pilates, Yoga or Dance studio before?

* 6. When did you feel the best in your life?

* 7. Nearly there all we need now is a little more information about your personal goals. 
Please indicate in the list below the goals that you would like to meet during your sessions.
5 = Goal that you would like to focus on strongly and 1 = Not a goal that you would like to focus on.

  Not a goal that you would like to focus on. Maybe a goal you would like to focus on. Not a goal that you would like to focus on immediately. A goal that you would like to focus on. A goal that you would strongly like to focus on.
Flexibility
Mobility of joints such as the hips and shoulders
Core Strength
Arm Strength
Leg Strength
Stamina
Endurance
Connecting through the whole body

* 8. To help us build you a successful package we would like to know what expectations you have and when you would like to see improvements in each of these areas.
Please select one of the time frame ranges below.

  1-2 weeks 3-4 weeks 1-2 months 3-6 months 6+ months
Flexibility of long muscles
Mobility of joints such as the hips and shoulders
Core Strength
Arm Strength
Leg Strength
Stamina
Endurance
Connecting through the whole body

* 9. Do you have a very specific goal that you would like to focus on? Such as running a marathon, being able to walk up a flight of stairs, being able to play with your children, not having aches and pains throughout the day, or something else completely. Tell us about it!

* 10. Would you like to hear more from BodyMap Studio?

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