Some Photos on this site are courtesy of Balanced Body Inc
Date of Birth
The Day you are
Do you ever feel pain in your chest when you do physical activity?
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:
List 3 specific goals you would like to accomplish and in what time-scale?
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?
If Yes, what are you doing?
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.