medical Form

Medical History Questionnaire
Name

First NameLast Name
Date of Birth
Occupation
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact Details
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Post Natal Information
Please comment below with each child's age and delivery method ( V- Vaginally or C - Caesarean)
Have you been for your 6 Week check up?

YesNo
Were there any complications. If Yes- please list details below
Have you been doing your pelvic floor exercises?

YesNo
Have you experienced any leaking, heaviness, urgency to go to the toilet?

YesNo
Are you aware of your Transverse Abdominals?

YesNo
Do you suffer from any back pain?

YesNo
Have you been assessed for abdominal separation? Gap (in fingers if known)
Do you or did you have any pelvic instability or pain throughout your pregnancy/pregnancies?

YesNo
Do you know if you have a weak or hypertonic( tight) pelvic floor? Details:
Do you have a prolapse?

YesNo
Female Specific Questions
Do you menstruate on a regular basis?
How long is your typical 'cycle'?
Do you currently have , or have has issues with your menstrual cycle? eg. irregular, missing cycles(and not pregnant), PMS?
At what age did you begin menses?
Have you ever been diagnosed or told you have PCOS, endometriosis or something similar?
Do you think you are pre-menopausal or going through menopause?
Have you had or are currently experiencing any hormonal related signs and symptoms such as hot flushes, weight gain, vaginal dryness, foggy head etc?
Has your mother/or father or siblings been diagnosed with (or had) osteoporosis?
Have you even had broken bones or stress fractures?
Have you been on diets before?
Have you had an eating disorder?
Other Medical Information
Has anyone in your family under 55 suffered from heart disease, stroke or raised cholesterol?

YesNo
Are you a male over 45 or female over 55 and NOT used to regular vigorous exercise?

YesNo
Do you ever experience unexplained pains in your chest at rest or during physical activity or exercise?

YesNo
Have you experienced an asthma attack requiring immediate medical attention at any time over the past 12 months?

YesNo
Are you known to have Type I or Type II diabetes?If so have you had trouble controlling your blood glucose in the last 3 months? Y/N
Are you currently on any prescribed medication?If yes please detail:
Have you been hospitalised in the last 12 months? (Including day admission)If yes please detail:
Are you pregnant? If yes please state how many weeks:
NOTE: If you have answered ‘YES’ to any of the questions above, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

If you answered ‘NO’ to all of the questions above, & you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.
Health Information
Do you suffer from any of the following?

High Blood PressureLow Blood PressureHigh CholesterolLow CholesterolAsthmaJoint reconstructionsHeart diseaseAllergiesJoint issuesDizzinessTendonitis
If ticked any of the above, please provide details below:
Please describe your current physical activity? (How many days, exercise type, how long for?)
What are your expectations of me as your trainer?
Bec Roberts Fitness- Terms and conditions
o Cancellation Policy for casuals:

Cancellation of appointment session will require a 10-hour notice period.
In extreme circumstances and situations this policy can be flexible and will be treated at the discretion of the personal trainer. To not show, or to not notify within the 10-hour period before your appointment time, the full session fee will stand.
o Session Time Policy:

The session will have deemed to start at the pre-arranged session time. Any loss of time due to late arrival will not be made up at the end of the session.
In the case of the personal trainer falling ill or being unable to instruct the session, the session will be cancelled and re-arranged at no charge to the client.
o Child Policy:

Parents/guardians are to take sole responsibility for their children throughout their fitness session, whether they are participating in the session or playing in the provided safe play space.
o Fees & Charging Policy:

All payments for sessions must be made prior to your session. Payments are made by either bank transfer or direct debit.

If paying by bank transfer please make payment to the details below:

Rebecca Roberts

BSB- 013915

ACC- 561331643
o Block Programs (blocks may vary in duration throughout the year)

Payment for these programs must be made either by 1 upfront payment or 2 half payments through a payment link that will be emailed to you. You will also have the option of weekly direct debit for the duration of that block.

1 class per week - $25

2 classes per week - $50

3 classes per week - $65

Casual sessions - $28

You will be commited to lock into the same session/s every week. There will be also the option of completing the workout from home through Zoom if you cannot make the class in person for any reason.

If for any reason you cannot attend your scheduled class, there may be the opportunity to make this up during the week if there is AVAILIBILITY.

If your trainer is unwell, you will have the option of completing the workout through a LIVE workout with your trainer on the otherside of the screen, or you may use you session as a make up class anytime throughout the block.

If you are taking HOLIDAYS over the block , you may have the opportunity to make up your session/s anytime throughout the block if there is availbility but FULL fees will apply.

I do not offer any credits for any missed classes.

Sessions CANNOT be rolled over to another training block
o Covid Policy

In the event that your face-to-face sessions cannot be delivered in this way due to any circumstances created by the COVID pandemic (or any other natural disasters or uncontrollable events) they will be delivered via a virtual face to face format instead.
No refunds or holds will be made for a change in delivery due to uncontrollable circumstances.
All members must comply with the current regulations and COVID safe recommendations (eg social distancing procedures, group sizes, hand hygiene, staying at home when unwell etc) in place at any given time.
Disclaimer
I recognise that the personal trainer is not able to provide me with medical advice with regard to my medical fitness and that the information is used as a guideline to the limitations of my ability to exercise safely. I understand that the information I have given on this form is correct to the best of my knowledge and any changes in circumstance Bec Roberts Fitness will be notified.
I also state that I wish to participate in activities, which may include, but not limited to, weights training, high intensity, cardiovascular, resistance training, boxing and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.
I have read and understood the terms and conditions above and agree to abide by them.
If any of the above information changes, the client must, in writing, let the trainer know before their next appointment.
Signature

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Clients Name:

First NameLast Name
Date

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Date
I grant Bec Roberts Fitness, its representatives and employees the right to take photographs of my property and me for such purposes as illustrations, advertising and web/social media content
Clients signature

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Should be Empty:

Medical History Questionnaire

Emergency Contact Details

Post Natal Information

Female Specific Questions

Other Medical Information

Health Information

Bec Roberts Fitness- Terms and conditions

Disclaimer