Intake Forms

Massage Intake Form

First Name

Last Name

Do you have any medical conditions? (e.g., heart disease, diabetes, etc.)

Are you currently taking any medications?

Do you have any allergies?

Have you had any recent surgeries or injuries?

Are you pregnant?

What are your primary reasons for seeking a massage? (e.g., relaxation, pain relief, improving flexibility, etc.)

Are there specific areas of tension or discomfort?

What type of massage are you interested in? (e.g., Swedish, deep tissue, sports, etc.)

Consent Signature

I understand that the massage I receive is provided for the purpose of relaxation and stress relief. I acknowledge that the massage therapist is not a licensed physician and that I should consult my doctor for medical advice.

Pilates Intake Form

First Name

Last Name

Photo Consent & Release

I consent for photographs and/or video images to be taken of me by BodyAligned PT & Pilates. or a representative. I understand the images will be a part of my medical record and may be used for purposes of medical teaching or training or for marketing purposes (website, print, digital or social media). By consenting to photographs and/or video images I understand I will not be compensated from any party. Although photographs and/or video images will be used without identifying information such as name, I understand it is possible someone may recognize me. I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever. I authorize the use of photographs and/or video images: (please initial indicating YES or NO below)

Do you have any medical conditions? (e.g., heart disease, diabetes, etc.)

Have you had any recent surgeries or injuries?

Are you currently taking any medications?

Do you have any chronic conditions (e.g., asthma, diabetes, heart issues)?

Have you practiced Pilates before?

What are your primary goals for practicing Pilates? (e.g., flexibility, strength, rehabilitation)

How often do you currently exercise each week?

How did you hear about our Pilates studio?

Is there anything else we should know about you or any other questions you have?

Consent Signature

Get in Touch With Us Today!

Take the next step towards a healthier, pain-free life! Contact BodyAligned Physical Therapy and Pilates Center in Loma Linda, CA, at 909-796-8400. Our friendly and knowledgeable team is here to answer your questions, schedule your appointments, and help you start your journey to optimal health and wellness.