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One-to-one and Small Group Booking Form

Health Questionnaire and Aims & Goals

Before completing the booking form you must read and agree our terms of booking  here>>

Phone No

Email Address

Date of Birth



The Day you are


Do you ever feel pain in your chest when you do physical activity?

Emergency Contact

Name / Number

The Session you are Booking

Have you ever been told you have high blood pressure?

Do you have a joint problem that could be made worse by exercise?

Do you ever feel faint or have spells of dizziness?

Have you ever had chest pain when you are not doing physical activity?

Are you currently taking any medication of which we should be made aware?

Are you pregnant or have you had a baby in the last 6 months?

Is there any reason you should not participate in physical activity?

Do you suffer from any condition, such as epilepsy or diabetes that we should be made aware of?

Has your doctor said you have a heart condition and you should only do physical activity  recommended by a doctor?

If you answered Yes to any of the above

Questions please provide details here

Aims and Goals

What brought you to


What aspects of your health or fitness would you like to concentrate on:


Weight Loss



Stress Reduction


List 3 specific goals you would like to accomplish and in what time-scale?

Goal 1

Goal 3

Goal 2



Hours per


Sitting at Desk

More than 25% of your day is spent on the following actions:

Lifting or carrying Loads




Do you consider your work to be:




Do you Smoke?

In the Past?

Are you exercising at present?

This form collects personal information. Check out our Privacy Policy to read how we protect and manage your submitted data.

I have read and agree terms of booking*

I consent to having Purely Pilates collect the information requested on this form to book me on a block of Pilates Sessions*

I consent to Purely Pilates contacting me by email to provide updates on what is going on at our studio.