New Client Screening Form

New clients

Exercise screening questionnaire

This screening questionnaire helps us gain a deeper understanding of you and your body, before you join us in the studio.

Progress

First name

Surname

Phone number

Date of birth

Occupation

Address

Suburb

Post Code

Name of emergency contact

Full name

Relationship

Phone number

Please provide details of any injuries, conditions or restriction you have, now or in the past.

Name of supervising doctor or health practitioners.

List any current medications, herbal or treatments.

List your current exercise activities, frequency and intensity.

When was your last bone density test...?

Are you pregnant...?

If yes, when is your due date...?

Have you recently (or ever) had a baby?

Are you going through or have been through menopause?

Have you ever undergone gynaecological surgery (e.g. a hysterectomy)?

Do you have a history of lower back pain?

Have you ever injured your pelvic region (e.g. through a fall or pelvic radiotherapy)?

Do you suffer from constipation or regularly strain on the toilet?

Do you have a chronic cough or sneeze (e.g. because of asthma, smoking or hayfever)?

Are you overweight, obese or having a BMI over 25?

Are you an elite athlete (e.g. a runner, gymnast or trampolinist)?

Do you frequently lift heavy weights (e.g. at work or at the gym)?

Accidentally leak urine when you exercise, play sport, laugh, cough or sneeze?

Need to get to the toilet in a hurry - or not make it there in time?

Constantly need to go to the toilet?

Find it difficult to empty your bladder or bowel?

Accidentally lose control of your bowel – or accidentally pass wind?

Have a prolapse (e.g. a bulge or feeling of heaviness, discomfort, pulling, dragging or dropping in the vagina)?

Suffer from pelvic pain or experience pain during or after intercourse?

Do you have or ever had any of the following conditions?

Please tick those conditions that apply:

Other conditions

Which part of your body...?

Goals

Have you previously registered with us...?

Have you previously done Pilates...?

How did you hear about Pure Pilates...?

Terms & conditions

By submitting this questionnaire you agree to participate at Pure Pilates at your own risk and you will act responsibly and safely.

You are agreeing that the information you have given in this questionnaire is true and correct. That you have read and understood all wording in this questionnaire.

That you will take full responsibility for your actions at any and all times on the premises of the Pure Pilates Studio or any other off-site venue; during any workouts, sessions, classes, practice and use of equipment in any way whilst engaged in activities with Pure Pilates or on their premises.

Bookings and cancellations

Please also note we are a boutique business and as such we need to run a “tight ship”. We ask for your appreciation and understanding of the following conditions:

- We have a strict 24 hours notice of cancellation of bookings policy or the full fee will be charged

- We do not offer refunds

- For those regular clients going on extended breaks, we are happy to extend the expiry date of your pack by two months

- For those going on extended breaks, please understand that we cannot hold your regular space as we need each Small Group Studio Session to be at the capacity of four clients to maintain business viability. We will of course try our very best to slot you back in at the most suitable time for you.

Ready to reignite your health & wellness journey...?

Pure Pilates

Your Health & Wellness Studio in Kingston.

A cooperative of like-minded qualified Pilates Practitioners and affiliates educators whose goal is to support you to achieve happiness, health and wellness.

With both private and group sessions, we’re able to provide you with individual and personalised care in our welcoming and inclusive space in Kingston, Tasmania.

Quick links

Thank you

We have received your health screening questionnaire.

If we haven’t already confirmed your first Introductory Session, we’ll be in contact soon.

And welcome to the Pure Pilates community.