Emergency Contact Person
How would you describe your current physical condition?
What regular exercise do you currently do?
Have you ever had OR do you have?
Heart murmur YesNo
Palpitations or pain in the chest:YesNo
High blood pressure <140/90:YesNo
Low blood pressure:YesNo
Are you, OR have you recently had or done any of the following?
Are you pregnant:YesNo
Given birth in the last 6 weeks:YesNo
Have you been hospitalised recently?:YesNo
Dieting or fasting?:YesNo
**Please Note: If you have circled YES to any of the above OR you are NOT SURE – We will recommend
that you see a doctor prior to beginning an exercise program
Have you ever had or do you have?
Did you, OR do you smoke?YesNo
Do you experience any pain OR major injuries particularly in the following areas?
Have you had any major surgery?
Are there any other conditions not mentioned which may be a reason to modify your exercise
MUMS AND BUBS – BABY AND MEDICAL INFO
Are you bringing any kids: YesNo
About your birth, VB? Complications or difficulties?
About your baby. Any health complications at birth?
How was your 6 week health check-up, were you given any recommendations?
Are you breastfeeding?
Did you have any diastasis recti? (separation of abdominal muscle)
If yes, how is the separation now?
Did you experience any back, pelvic or pubic pain while you were pregnant?
If yes, did you receive any treatment?
Are you currently experiencing any pain in your body?
If yes, where and for how long? Are you receiving any treatment?
Is there anything else you feel the trainer needs to know before commencing your fitness program?
I have read and understood the Terms and Conditions and know that it affects my legal rights.