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Fit Mums – New Client
Step
1
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- Contact Information
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Contact Information
Name:
*
First
Last
Date of Birth:
*
Day
Month
Year
Email Address:
*
Phone Number
*
Address:
*
Street Address
City
ZIP / Postal Code
Baby's Name:
*
Baby's Date of Birth:
*
Day
Month
Year
General Medical Questions
The following information is required to ensure that our classes are safe and exercises are suitable. All information will be kept confidential.
Please check the box to the left of the condition if you have any of the following:
Heart Disease
Diabetes
Epilepsy
High Blood Pressure
Asthma
Other Respiratory Disease
History of Prolapse
Less than 6 Weeks Post-Birth
Are you taking any Medications, pills, tablets or supplements that may effect your training?
*
No
Yes
If Yes, please list or describe your current medication.
Pregnancy, Birth & Beyond
How many pregnancies have you had?
*
How many children do you have? (Any multiple pregnancies?)
*
Did you experience any challenges/medical issues during your pregnancy (high blood pressure, carpal tunnel syndrome, pelvic instability…?)
*
No
Yes
If Yes, please give a breif description below
Did you exercise before and/or during your pregnancy?
*
No
Yes - Before Pregnancy
Yes - During Pregnancy
Yes - After Pregnancy
What exercise did you do BEFORE your pregnancy?
What exercise did you do DURING your pregnancy?
What exercise did you do AFTER your pregnancy?
What type of delivery did you have (include detail of tears/episiotomy/vacuum/forceps)?
Were there any complications/issues post-delivery?
No
Yes
Details of complications/issues post-delivery?
Did you have an abdominal separation post-birth?
No
Yes
How wide was/is this? How have you treated this so far?
Exercise History & Current Injuries
Do you currently suffer from any of the following musculoskeletal complaints?
Back Pain
Bladder Problems
Dizziness
Knee Pain
Pelvis Pain
Wrist Pain
Do you have any other medical or musculoskeletal condition/injury?
Have you seen a physio/osteopath or a medical professional post-birth? If yes, was there any specific intervention given…
What are your main reasons for attending our FIT MUMS classes?
Enhance core strength
Enhance overall body strength
Tone upper and lower body
Regain fitness / cardio
Weight loss
Social interaction
Other
Please list the other reasons you have below
Please read through our authorisation and agreement policy for all our exercise classes and sessions.
Agreement & Authorisation Policy
I have disclosed all medical information on this form. I understand that it is my responsibility to inform the instructing physiotherapist of any new injuries or changes to my medical condition prior to participating. I acknowledge that I participate at my own risk and exonerate
Max NRG Personal Training Pty Ltd.
trading as
'Moonee Valley Health and Fitness'
and their instructors from all liability should I become injured. I acknowledge that in the classes it is my responsibility to take care of my baby.
Agreement
*
I agree to the Agreement & Authorisation Policy
Terms & Conditions
I wish to participate in the activities and programs of
Max NRG Personal Training Pty Ltd
ABN 48 045 374 949 trading as
'Moonee Valley Health and Fitness'
.
I understand that:a) Portions of the exercise and training program may occur outdoors.b) Exercise carries some risk including, without limitation, risk to the musculoskeletal system and to the cardio respiratory system.
In consideration of Moonee Valley Health and Fitness agreeing to provide training and fitness activities and programs, I release Max NRG Personal Training Pty Ltd, its employees and representatives from any and all responsibilities or liability from injuries or damages resulting from or ancillary to my participation in any activities or my use of the equipment.
I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury or death, and that I am voluntarily participating in these activities and using equipment with knowledge of the dangers involved. I agree to expressly assume and accept any and all risk of injury or death.
I agree that I have no undisclosed injury or illness that may affect my ability to undertake rigorous exercise and to the best of my knowledge I are ready and able to undertake this exercise program.
I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity exercise and use of exercise and training equipment, so that I might have his/her recommendations concerning these fitness activities and equipment use.
I acknowledge that I have either had a physical examination and been given my GP's permission to participate, or that I have decided to participate in the activity and use of the equipment without the approval of my GP and assume all responsibility for my participation in activities, and utilisation of equipment in my activities.
Finally, I acknowledge and agree that no warranties or representatives have been made to me by any representative of Moonee Valley Health and Fitness regarding the results I will or may achieve from any program conducted at Moonee Valley Health and Fitness. I understand that results are individual and may vary.
Agreement
*
I agree to the terms
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