Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
DOB
*
Email
*
Mobile
*
How would you rate your overall health and lifestyle ( 1 - Unhealthy to 10 - Healthy)?
1 - Unhealthy
2
3
4
5
6
7
8
9
10 - Healthy
How would you rate your overall nutrition ( 1 - Unhealthy to 10 - Healthy)?
1 - Unhealthy
2
3
4
5
6
7
8
9
10 - Healthy
How would you rate your activity level (this is all the activity you may do during the week such as walking, gardening etc., as opposed to formal exercise such as swimming or going to a class ( 1 - Inactive to 10 - Very active)?
1 - Inactive
2
3
4
5
6
7
8
9
10 - Very active
Do you smoke or use e-cigarettes?
Yes
No
Approximately how many units of alcohol would you consume in an average week (1 Unit = 1/2 pint of medium strength beer or a small glass of wine)?
What exercise do you currently do (please don't worry if the answer is none)?
What do you think are the main benefits of exercise to you?
Please state 3 goals you would like to achieve through your training with CLC Fitness below. This will help me to tailor our sessions so you can get the most from them.
Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?
Yes
No
Do you have chest pain brought on by physical activity?
Yes
No
Have you developed chest pain in the last month?
Yes
No
Do you tend to lose consciousness or fall over as a result of dizziness?
Yes
No
Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
Yes
No
Have you had an operation in the last 6 weeks?
Yes
No
Are you on any medication (please state below)?
Are you currently pregnant?
Yes
No
Do you have any other medical conditions/injuries/strains? Please state below.
Are you aware, through your own experience or from a doctor's advice, of any other physical reason, why you should not exercise without medical supervision?
Yes
No
If you have answered YES to any of the questions above, I confirm that I have sought advice from a medical professional who has approved me to exercise.
Yes
No
What is your baby’s name?
What is your baby's date of birth?
Do you have any other children? If YES, please state their ages below.
What type of delivery did you have? Please state this for each delivery if this is not your first baby.
Did you experience a third or fourth degree tear during childbirth or have an episiotomy? If YES, please state which below.
If you had a c-section, have you experienced any discomfort, loss of sensation or slow healing in relation to your c-section scar? If YES, please provide details below.
Have you had your postnatal check-up?
-
Yes
No
If there were any issues arising from your check up, please give details.
Are you/were you a regular exerciser before becoming pregnant?
-
Yes
No
If YES, please let me know what you enjoyed doing.
Are you currently breastfeeding?
-
Yes
No
Are you currently or have you previously been under the care of a pelvic health physiotherapist?
-
Yes
No
If YES, please give details
Are you experiencing any symptoms relating to your pelvic floor. These may include symptoms of bladder or bowel weakness (such as leaking when laughing, coughing, sneezing, jumping or moving quickly) feelings of heaviness, pain or dragging or have been diagnosed with a prolapse?
-
Yes
No
If YES, please give details
Are you aware that you have an ongoing diastasis recti (split in your tummy muscles)?
-
Yes
No
Do you suffer with back or sciatic pain?
-
Yes
No
If YES, please give details
Do you suffer from any other conditions that may affect you during participation?
-
Yes
No
If YES, please give details
Do you do/intend to do any other exercise in addition to this class?
-
Yes
No
If YES, please give details
Any additional comments or concerns:
Client e-signature
*
Date
MM
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