Send Medical Registration Form

 

You’ll need to complete this form before beginning the programme.

This allows your qualified FitBack & Bumps instructor to make sure there aren’t any medical reasons that you shouldn’t begin the programme and helps to keep you as safe and healthy as possible.

All questions contained in this questionnaire are strictly confidential .

To:


PERSONAL INFORMATION

Your Name

Your Email

Address

Telephone Number

Emergency Contact Name & Number

Date Of Birth

Which class are you interested in?
 Antenatal Postnatal

What's your due date (if applicable) ?

Current weight

Weight prior to pregnancy

Height

Name Of Doctor

GP's Practice Name & Address

Doctor's Telephone Number

PERSONAL HEALTH HISTORY

Please list any past medical problems diagnosed

Did you exercise regularly prior to becoming pregnant?
 Yes No

Have you exercised during your pregnancy?
 Yes No

If Yes, please provide details

Is/Was this your first pregnancy?
 Yes No

Have you ever suffered miscarriage in a any previous pregnancies, vaginal bleeding or other complications?
 Yes No

If yes, please provide details

Are you having/Did you have any medical treatment for complications in your pregnancy?
 Yes No

If yes, please provide details

If you are currently pregnant have you been diagnosed with Placenta Previa?
 Yes No

Please answer these questions if you are interested in a postnatal class

Date of delivery

How many weeks postnatal are you?

Did you have a C-Section?
 Yes No

Have you had your 6 week check?
 Yes No

MEDICAL HISTORY

Please answer the following questions carefully.

Do you or have ever you ever been diagnosed with any of the following:

1. Symphysis Pubis Dysfunction  Yes No
2. Serious heart, respiratory, renal or thyroid disease  Yes No
3. Type 1 or Type 2 diabetes  Yes No
4. Asthma  Yes No
5. Anaemia  Yes No
6. Epilepsy  Yes No
7. Swelling in hands, ankles or face  Yes No
8. High or Low Blood Pressure – Pre-eclampsia?  Yes No
9. Urinary tract, bladder or kidney infection – in the last year?  Yes No
10. Do you suffer any problems in controlling urination?  Yes No
11. Have you been diagnosed with extreme obesity?  Yes No
12. Are you on any medication?  Yes No

If you answer yes to any of the questions above, please provide details below.

CLIENT DISCLAIMER

PLEASE NOTE: You must agree to the client disclaimer below before participating in our classes. Please read and tick in the box provided before participation in the classes.

Every precaution will be taken to ensure your safety during participation in these classes. With that in mind, you are aware of the nature of the classes and any risks involved. You acknowledge that certain elements of the classes will be physically demanding. You agree that you are physically capable of participating in the sessions and accept full and complete responsibility for your own participation in the class. You agree that should any medical or physical problem arise prior to or during a class which is likely to affect your ability to participate in a class, you will withdraw from the session. FitBack & Bumps Ltd and your Physiotherapist Instructor shall not be liable to you for any indirect or consequential loss or damage including loss of earnings arising out of your participation in classes. If there is anything else we need to know regarding your health & fitness, please provide details above in the Prescreen Medical Questionnaire.

I agree to the terms and conditions stated above

( You must agreed to the above terms to submit the form)