Client Health Assessment for PT's in Australia

Prep 4 Birth™ / Birth Ball Basics™ Registration

Sunday 14th September - 9:30am to 12:30pm - Inverell
What You’ll Get from the Prep 4 Birth Workshop:

Through a mix of targeted exercises, stretches, and practical education, you’ll walk away with: Stronger core & lower body muscles to support your growing belly and improve posture. Improved mobility & balance to ease pregnancy discomfort and prepare your body for labour. Movement strategies for birth to help manage contractions and support smoother labor progression. Confidence in your birth prep journey—with tools to continue training your body for the big day. Support & connection, plus a guide to trusted local, mum-focused businesses to add to your pregnancy and postpartum team. For more information email Jo at reignitewomensfitness@gmail.com
Choose your session

Sunday 7th SeptemberSunday 14th SeptemberCan do either
Personal Details
Name*

First NameLast Name
Are you the person who will be taking the class? If not, please write the participant's name below.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Email*
example@example.com
Age*
Emergency Contact*

First NameLast Name
Emergency Contact Mobile*
Pregnancy
Is this your first pregnancy?

YesNo
What is your Estimated Due Date?
Do you have medical consent to exercise?

YesNo
Is your baby breech?

YesNo
Do you have any current or past injuries which we should be aware of?*

YesNo
If so, please specify what the injury is/was, how long ago it occurred and how it was treated?
How do these injuries prevent you from performing certain exercises?
Pre-Exercise/Activity Screening Form
This screening tool does not provide advice on a matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by "Reignite Women's Fitness", 4th Trimester Fitness Method, Exercise and Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.
Full Name
DOB
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke*

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

YesNo
Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*

YesNo
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

YesNo
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?*

YesNo
Have you spent time in hospital? (including day admission) for any medical condition/illness/injury during the last 12 months?*

YesNo
If "Yes" please provide details:
Do you have any other conditions that may require special consideration for you to exercise?*

YesNo
Please specify what they are:
IF YOU ANSWERED ‘YES’ to any of the questions above, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.
IF YOU ANSWERED ‘NO’ to all of the questions above, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.
I herewith confirm that if I have selected "Yes" in one of the questions above that I have contacted or I will contact a GP or an appropriate allied health professional for guidance before undertaking physical activity/exercise.*

Yes
I believe that to the best of my knowledge, all the information I have supplied within this tool is correct.
Signature*

Clear
Date signed
Photo/Video Waiver Release Form
I, the participant specified below, acknowledge that I may be photographed or videotaped during training. I hereby consent to the use of these photographs and/or videos without compensation, on the 'Reignite Women's Fitness' or "4TFM' social media accounts/pages or in any editorial, promotional or advertising material produced and/or published by 'Reignite Women's Fitness' or '4TFM'.
Client's Name*

First NameLast Name
Client's Signature*

Clear
Date signed:
Release and Indemnity to the Fitness Trainer
The “Trainer” means "Reignite Women's Fitness" Trainer”. The “Activity” means the participation in Prep 4 Birth™ workshop.

Agreement:

I acknowledge that it is a condition of participating in this activity that I do so at my own risk. I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands, and proceeding arising out of or connected with my participation in this Activity. This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns.

I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: Over exertion, dehydration, equipment failure and accidents with equipment and/or surroundings. I recognise the difficulties associated with the Activity and attest I am physically fit to participate safely in the Activity and that a qualified medical practitioner has not advised me otherwise. I understand the demanding physical nature of this Activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this Activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my trainer will be immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and am still, and will always be under the terms of this agreement.

I certify that I am 18 years or older and have read this document and fully understand it.

Authorisation: All completed information is accurate and true responses by the undersigned.
Client's Name*

First NameLast Name
Client's Signature*

Clear
Date signed:
Trainer's Name
Trainer's Signature

Clear
Date signed:
Payment
Early bird price $129.99 only valid until 20th June 2025.
Use coupon code "EARLYBIRD" for $20 off. Only valid until 20th June 2025, 11:59pm.

Note: It is your responsibility to include the coupon code below at time of purchase. There will be no reimbursements if you miss adding the code.

My Products

Prep 4 Birth WorkshopThe only Birth Ball workshop in Inverell to empower and educate mums-to-be on ways to use a birth ball in pregnancy and beyond. Labouring techniques, how to move to move baby. Comfort measures to ease common pregnancy complaints & sleep well. Includes take home birth ball workout. BYO ball to the class.

$149.99AUD Quantity

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$0.00AUD

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Jolene Hilet | Pregnancy & Postnatal Specialist | Reignite Women's Fitness

Mobile: 0457 158 933 | Email: reignitewomensfitness@gmail.com
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Prep 4 Birth™ / Birth Ball Basics™ Registration

What You’ll Get from the Prep 4 Birth Workshop:

Personal Details

Pregnancy

Pre-Exercise/Activity Screening Form

Photo/Video Waiver Release Form

Release and Indemnity to the Fitness Trainer

Payment

Use coupon code "EARLYBIRD" for $20 off. Only valid until 20th June 2025, 11:59pm.

Jolene Hilet | Pregnancy & Postnatal Specialist | Reignite Women's Fitness