One to One booking form

One to One Client interview/booking form and PARQ
The information on this form will help us prepare for your first lesson. Please note, full payment will be required prior to your lesson, after a day and time has been agreed.

* Indicates required field

Email *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Emergency contact name and number *

How many times a week can you commit to home practice between your one to one lessons? *

What is your occupation and hours of work? *

Do you have any particular personal circumstances which you feel may affect your progress? (if so, please specify) *

What types of exercise do you like/dislike and are you exercising at the moment? If yes, what are you currently doing and how often? *

What are your motives for exercising and what are your personal health/fitness goals? *

When would you like your one to one lesson/s? Please give the day of the week and ideal time? This will be confirmed or rescheduled if a teacher is not available. *

Agreement:

We will make every effort to accommodate your booking, however dates and times are subject to availability.
By submitting this booking form and making payment, you understand that payment cannot be refunded if you are unable to attend.
Full payment for services is required in advance.
You need to complete the Physical Activity Readiness Questionnaire (PARQ) below.
By submitting this booking form, you have asked to receive emails and communications from us. This will keep you informed on current services available. You can unsubscribe at any time. This is following General Data Protection Regulations (GDPR) 25th May 2018.

Health Screening:
Please answer each question with a yes or no. (All information will be treated confidentially)

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

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

In the last month, have you had chest pain when you are not doing physical activity? *

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Do you have a bone or joint problem, for example, back, knee or hip? If you answer yes you are advised to seek advice from a health care professional first. See declaration below *

Is your doctor currently prescribing drugs for blood pressure or a heart condition? If you answer yes you are advised to seek advice from a health care professional first. See declaration below *

Are you pregnant or have you had a baby in the last 6 months? If you are pregnant, how many weeks will you be for your 1st class *

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

IF YOU HAVE ANSWERED YES TO ONE OR MORE QUESTIONS
You should talk to your doctor by phone or in person before you start becoming more physically active. Tell your doctor about the questionnaire and which questions you answered YES to. Please also tell your instructor. If you have already got medical clearance for Yoga/Pilates or moderate exercise in general, please fill in the declaration below.

You may be able to do any activity you want – as long as you build up slowly and gradually. Or you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activity you wish to participate in and follow his/her advice. Yoga/Pilates exercises are generally safe for most people, it improves flexibility and strengthens your deep postural muscles – particularly your deep abdominals and back muscles – as well as improving your overall posture and body awareness, thus minimising the chance of future injuries.

IF THE ANSWER IS NO TO ALL QUESTIONS you can reasonably be sure that you can start to become more physically active and take part in a suitable exercise programme. Begin slowly and build up gradually!

PLEASE NOTE

If your health changes subsequently so that you answer YES to any of the above questions and you have started a class with us, please inform your teacher.
If you are temporarily unwell (e.g. cold or flu), delay becoming more active until you are better.
If your doctor has recommended that you avoid any movements, make sure that you let your teacher know.

By submitting this booking form you confirm you have read and understand this questionnaire. If you have any concerns, contact us by email and ensure you speak with your instructor at the start of your class.

DECLARATION This applies if you have answered yes to any of the above questions. I declare I have been cleared by my doctor (GP, specialist or other qualified health professional) to take part in moderate exercise. Please input your full name to indicate your informed consent. *

Submit

Price:
One to one private session £55 (discounts are available for block bookings). Sessions take place in your own home (or at a location you choose) and at a time convenient for you. This price is for a one hour session local to Hornchurch and Basildon. We can also offer small bespoke classes, please get in touch if you would like to discuss this option.

Absolute Yoga and Pilates;
'Friendly classes that help you enjoy a healthy and balanced life'

t: Pauline 07821 969405
e: [email protected]

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One to One Client interview/booking form and PARQThe information on this form will help us prepare for your first lesson. Please note, full payment will be required prior to your lesson, after a day and time has been agreed.

One to One Client interview/booking form and PARQ
The information on this form will help us prepare for your first lesson. Please note, full payment will be required prior to your lesson, after a day and time has been agreed.