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Outdoor sessions Screening form
*If you are pregnant or have recently had a baby please complete the pregnancy or postnatal screening form*
Name
Date of Birth
Mobile
Email
Address
Emergency Contact (Name & Number)
What are your main goals, aims or reasons for starting with FemmeBods?
Prior to joining Femmebods have you been doing any regular exercise? Please give details below
How would you describe your nutrition?
How well do you sleep? Also please give an indication of hours per night.
GENERAL HEALTH - Do you have any of the following?
Are you or have you been seeing a health practitioner for any injuries, illness or muscle soreness
Heart condition
Chest pain when exercising
Loss of balance due to dizziness
Back, Pelvic or other joint pain that could be made worse by exercise
High or low blood pressure
High cholesterol
Diabetes
Epilepsy or a history of fits
Asthma
Constipation/IBS/Coeliac or Crohn's disease
Current or previous eating disorder
If you have selected any of the above, please provide details here
Are you pregnant? If so, how far along are you
Do you have children? If so, what age are they?
Has a previous pregnancy or birth led to any of the following?
Current of previous pelvic floor issues
Current or previous urinary issues
Current or previous bowel issues
Diastasis Recti (separation of the abdominal muscles)
Cesarean scar pain or discomfort
If you have selected any of the above, please provide details here
Are you taking any medication? If so, please specify
Have you had any major surgeries or other physical trauma?
Do you smoke? If so, how much?
Anything I have missed that you think is important for me to know
I, the client have answered the above questions truthfully to the best of my knowledge. If there are any changes to my health I will inform my trainer.
Select
Yes
During exercise sessions every effort is made to keep the session safe and minimise risks whilst providing an effective session. I, the client, am participating of my own free will and am aware, as with any exercise programme, there is a risk of injury. If I am feeling any discomfort or uncertainty throughout a session I will stop immediately and consult the trainer. I will not hold Femme Bods or staff liable in any way for injuries or illness that may occur while I am training.
Select
Yes
I understand that occasionally photographs will be taken for advertising and promotion. I am happy for pictures of me to be used for these purposes.
Select
Yes
No
Yes, but I would like to see and "ok" the images before they are used
When are you looking to start outdoor strength sessions?
Which session times are you interested in and how many per week? Eg 6am, 9.30am or 5.30pm & 1, 2 or 3
Best time and method to contact you
I have read the Terms & Conditions, if not, please do so now at https://www.femmebods.nz/outdoor-strength-sessions-terms-and-conditions/
Select
Yes
Address
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about me
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outdoor strength sessions
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