Name
*
First Name
Last Name
Email Address
*
Phone Number
*
Address
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State is South Yorkshire
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age
Date of birth
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Please add month of birth first
MM
DD
YYYY
Emergency contact number
*
Next of kin
*
GP
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Due date if pregnant
MM
DD
YYYY
Date baby born if postnatal
MM
DD
YYYY
Type of Birth
What Motivated you to contact Kate Campbell Fitness
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Exercise - Mobility - Antenatal - Postnatal - Weight loss - Nutrition or other (Please state)
How might we be able to offer support
In the past 4 months describe your activity level
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Sedentary Moderate or High intensity (Please state type of activity)
What if any significant changes have occured between the past and present
If weight loss is important to you, tell me about your weight or dieting history
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What are your goals?
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Choose the 3 most important
Weight loss
Weight gain
Improve Cardio fitness
Nutritional guidance
Improved muscle tone
Running improvement
Reshape body
Specific sports conditioning
General healthier lifestyle
Reduce muscular tension
Increase flexibility
Stress management
Gain strength
Rehabilitation
Pre-pregnancy health and fitness
Drop a dress/jean size
Postnatal restore and connect
Exercise goal
How long have you been thinking about these goals?
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What mode of training do you prefer?
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Walking
Jogging
Classes
Weights
Other
What methods do you prefer?
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Mixed
Group
Personal Trainer
Competitive
Non-competitive
Preferred training environment
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Outdoors
Studio
Gym
Home
Office
Preferred equipment
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If you wish to exercise at home please list all the equipment you have available at home.
Cardio machines
Resistance machines
Body weight
Free weights
Other
List all your home equipment
*
In the past what barriers have prevented you reaching your goal and why?
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Please comment in the box below on each one you tick
Physical
Motivational
Emotional
Availability
Time
Attitude
Fear
Cost
Family
If you have tried in the past, what has stopped you succeeding?
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Medical History: Have you ever had any of the following?
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If yes please provide more detail in the comments box below
Heart problems
Undergone surgery in the last 12 months
Balance problems
High/low blood pressure
Hay fever
Asthma - bring inhaler to session
Arthritis
Sports injury now or previously
Muscular aches or pains
Back problems
Pelvic floor problems now or in the past
On-going medical treatment
On-going treatment from a Physio, Chiropractor or Osteopath
Are you pregnant?
Have you had a baby in the last 6 months? If yes you will also need to complete the Postnatal screening form
None of the above
Further medical details
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Do you know of any other reason why you should not take part in a physical activity programme?
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List any medications you are currently taking and why they have been prescribed.
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Coronary Heart Disease Primary risk factors
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Please tick all that apply
Smoke
High blood pressure
High cholesterol levels
Diabetes
Lack physical exercise
Have an abnormal resting ECG
None of the above
Coronary Heart Disease Secondary Risk Factors
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Any clients that fall into one or more of the following categories should see their GP for medical clearance prior to testing and exercising.
• Any clients 35+ with one major risk factor
• Any client under 35 years with two major risk factors
Obesity > 2 stone overweight
Any symptoms of stress
Diet and eating disorders now or in the past
Drugs and alcohol abuse
None of the above
If Ticked anty of the above : Please give further details
Informed consent and waiver
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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.
COVID-19
By ticking this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you may be exposed to or infected by COVID-19 by attending Kate Campbell Fitness and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Kate Campbell Fitness may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Kate Campbell Fitness employees, volunteers, and programme participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Kate Campbell Fitness. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Kate Campbell Fitness employees, Freelance instructors and self-employed personal trainers, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Kate Campbell Fitness, its employees, Freelance instructors and self-employed personal trainers agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Kate Campbell Fitness programme.
I agree
Terms and conditions
*
By ticking I have read agree and accept the terms and conditions available in the footer of this webpage
I accept