Antenatal Screening Form — Kate Campbell Fitness

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Antenatal Fitness Screening Form

The information collected in this form will be used only for the purpose of designing an appropriate fitness programme for you and will not be disclosed to any third party without your consent.

We reserve the right to request a doctor’s clearance before allowing you to receive personal training with Kate Campbell Fitness.

Please fill out the form as thoroughly as possible.

Name *

First Name

Last Name

Email Address *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number *

Emergency contact number *

Due Date *

YYYY

How did you hear about Keep Mums Fit *

Word of mouth

Relative

Midwife

Internet search

Social media

Newspaper

Flyer

Park notice

Previously Attended

Antenatal History *

Please Ensure the following information is correct. If you have any previous or current medical conditions, injury or disabilities you may need to speak to your GP or Physiotherapist before you attend. Do any of the following apply to you?

Heart Disease

Epilepsy

Diabetes

Asthma

High blood pressure

Persistent vaginal bleeding

Placenta previa

Back or joint problems

Multiple pregnancy

History of premature labour

Been told to avoid exercise

First pregnancy

None of the above

If you have ticked any of the above please give further details *

Are you taking any medication, have any other health problems, or have any comments on the above? *

If you would like a program designing gym or home please list the equipment you have and the days you can train.

weights, kettlebells, bands, gym equipment, cardio machines

Exercise History *

Tick the type of exercise you did regularly before becoming pregnant

Gym

HIIT

Weight training

Cycling

Pilates

Running

Group Exercise

Personal Training

Yoga

No regular exercise

Please state your main goals, aims or reasons for attending Keep Mums Fit group classes or personal training. *

Informed Consent and Waiver *

Informed consent and waiver * I hereby state that I have read understood and answered honestly the screening questionnaire. During the exercise programme, every effort is made to keep the class / session safe and minimise the risks whilst providing an effective session. I am participating of my own free will and I am aware, as with any exercise programme, there is a risk of injury. I agree to participate in the exercise programme described to me by Kate Campbell and the Kate Campbell Fitness Team I understand that in order for the session to remain safe, alternatives and adaptations will be made throughout. The structure, purpose, benefits and risks of the session will be explained throughout the class, and I understand that I may withdraw from the session at any time. I understand it is my responsibility to inform Kate Campbell fitness staff if any physical / Medical changes occur which may prevent me from exercising safely. If at any time you feel undue pain or excessive discomfort, Stop the activity and inform instructor.I understand that from time to time photographs will be taken for advertising and promotion, and i agree to have any pictures of me used in this way. I will not hold KATE CAMPBELL FITNESS or staff liable in any way for injuries or illness that may occur while I am training.

I accept

Terms and conditions *

By ticking I have read and agree to the terms and conditions available in the footer of this website

I accept

Thank you!