PERSONAL DETAILS

Your Name

Date of Birth

Mobile

Your email

Your Address

Emergency Contact Name

Emergency Contact Number

Baby name

Baby Date of Birth

Have you had your 6-8 week postnatal check up?
YesNo

Has your GP advised you are safe to exercise?
YesNo

BIRTH INFORMATION

please select all that applies and complete if your baby is less than 1 year old. If your child is older 1 please move onto Health Overview.

Stitches presentTraumatic vaginal birthC-sectionNone of the above

HEALTH OVERVIEW

Please select all that apply

Shortness of breathAsthmaSeizuresHeart diseaseEating disorderGestational diabetesChest painCarpal tunnel syndromeVaricose veinsJoint or muscular painsLow or high blood pressureDizzinessSeparation of abdominal muscles / DiastasisSymphysis Pubis DysfunctionSacrum or Sacroiliac Joint PainHeavy Leakage of UrinePersistent bleedingPelvic Floor PainSign of InfectionPoor healingPain – abdominal, pelvic, back or otherExcessive fatigueIncreased pelvic pressurePainful breasts / breast abscessBreast discomfortNone of the above

For anything selected above please provide further details and whether it is past or current:

Are you currently taking any medication? If Yes, please give details below:
YesNo

Are you currently breastfeeding?
YesNo

Is there anything not mentioned above that you feel could affect your ability to exercise?
YesNo

DECLARATION

If you selected YES to one or more condition in the health overview section
Talk to your GP by phone or in person before you start becoming more physically active. Advise your GP about this questionnaire and talk with them about the kind of activity you wish to participate in and always follow their advice.
If you selected ‘None of the above’ in the health overview section
It is reasonably safe for you to start to become more physically active and take part in a suitable exercise programme. Start slowly and gradually build up your physical activity levels.

IMPORTANT

If your health changes at all or you develop any of the above health conditions, then please inform your instructor and GP / health professional immediately.

PHOTOS and CHILDREN

I am happy to have my photo / video taken for social media and advertising
YesNo
I understand that I have full responsibility for both my buggy and my child / children.
YesNo
I understand that I am fully responsible for myself and my children / children I am in charge of to adhere to government guidelines on social distancing and COVID regulations.
YesNo
I am happy to be part of any social media / whatsapp group for Fresh Hope Fitness to communicate with me
YesNo

Declaration

I understand and I am aware that strength, flexibility and aerobic exercise, including the use of equipment, indoors and outdoors, are potentially hazardous activities. I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved.

I confirm that I have read, understood and accurately completed this questionnaire, consulted with my GP if necessary and that it is my responsibility to ensure the safety of myself and my child / children when participating in any of the classes / sessions.

Name

Date

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