Client health questionnaire 151116

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Client Questionnaire and Health Screen Form Personal Details





Name: _________________________________________________________________ Date of Birth: ________________

Age: _____

Mobile phone: _______________

Email Address: __________________________________________________________ Home Address: __________________________________________________________ Children attending with you: Name _______________________________________ DOB _________ Age______ Name _______________________________________ DOB _________ Age______ Emergency Contact: __________________________

Phone:_____________

Pre-exercise health screening Please circle the most accurate answer: 1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

No

2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Yes

No

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Yes

No

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

No

5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

Yes

No

6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Yes

No

7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

Yes

No

IF YOU ANSWERED ‘YES’ to any of the 7 questions above, please advise your trainer and seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

Are you pregnant? YES NO If yes, how many weeks? ______ If recently postnatal, have you received your 6-week medical clearance from your doctor/midwife? YES NO N/A Have you been checked by your medical professional for abdominal separation (Diastasis Recti)? YES NO N/A If yes, how many centimetres? _________



Motivation, goals and exercise habits What outcomes would you like to experience as a result of attending Pram Power classes?

q Fitness q Increased Strength q Feel Better q Have fun

q Confidence in how I look q Lose the baby weight q Bonding with my baby

q q q

Confidence as a Mum Have some “me” time Make new friends

What is the single most important goal for you to achieve? ______________________________________________________________________ In what time frame do you expect to achieve your goals? ________________________ Did you exercise during prior to/during your pregnancy?

Yes

No

Are you currently exercising?

Yes

No

What activity are you now doing? Walking

Running

Pilates

Yoga

Gym

Other group exercise

Please list below any current injuries, pain or soreness. _________________________________________________________________ Please provide details on any previous injuries. __________________________________________________________________



Photos and video taken during class may be used on social media and our website. Please let us know if you do not want images or video published online. All new clients will be added to our newsletter mailing list used for Pram Power communication only. Your information will not be shared with any other organisations. Indemnity in Favour of Pram Power I acknowledge that I have sole responsibility for my personal safety, the safety of my child or children, possessions and exercise equipment at all times during the session. I acknowledge that participating in exercising activities carries with it some potential hazards and risks, and I release Pram Power, its directors, employees, and agents from any liability resulting from accident or injury during any exercise or participating in any activity associated with a Pram Power program. urther, I indemnify Pram Power and its directors, employees, and agents in relation to any claim of damages, loss, or injury to myself or my children arising out of my exercise or participating in any activity within the Pram Power program.

Please sign to confirm all information is correct and complete. Signed:

_________________________

Date:

_________________________

How did you hear about Pram Power? q Another mum q Internet search q Facebook

q q

Flyer GP

If you heard about us from another mum, we’d like to thank them, could you tell us who referred you? ________________________________