Physical Activity Readiness Questionnaire

Physical Activity Readiness Questionnaire

Health Screening and Liability Waiver - The Unruly Mum
Full Name*

First NameLast Name
What is your age?*
What is your gender?
Contact Number
Email Address*
example@example.com
Tick if you suffer from any of these conditions:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Check the symptoms that you' re currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
Have you been told that you are not medically cleared to exercise?*

YesNoNot Sure
Is there any other medical condition which you have not previously declared? If so, please do so below with a description of how this impacts you and your ability to exercise.*
Have you given birth (in any manner) within the past 12 weeks?*

YesNoNot Sure
If yes, please detail the birth - any complications (physical and emotional) and confirm you have been medically cleared to exercise.
Regardless of age, do you have any problems which you attribute to pregnancy, labour or any part of carrying/birthing a child?*

YesNoNot Sure
If yes, please detail the birth, the complications you have been faced with and any limitations that may place (of which you are aware) on joining in with The Unruly Mums.
Do you use any kind of tobacco or have you ever used them (no judgement from me!)?
Is there anything that has not been covered in this screening that you wish your Coach to be made aware of? This can include physical issues, emotional wellbeing, pressures at home/work which may impact on your training.
I understand it’s my responsibility to cease exercise and report any unusual feelings (e.g. chest discomfort, heart palpitations, or unexpected shortness of breath) promptly to my Doctor and inform The Unruly Coach on frankii@theunrulycoach.com *
I understand that The Unruly Mum is a general fitness programme and while The Unruly Mum will do their best to modify and adapt exercises for individuals, this is not an individualised programme. The sessions will likely include (but are not limited to) bodyweight strength and conditioning training with high and low impact options. If I use equipment, The Unruly Mum cannot take any responsibility for injury resulting in the use of the same. I understand following a fitness programme can have significant benefits for my general health and well-being but as with all physical exertion there are some risks such as minor musculoskeletal injuries (e.g. bruises, strains and sprains) and less frequently serious injury and/or illness. I accept these risks. I hereby hold, Francesca Newbery (trading as The Unruly Mum) exempt from any and all claims, demands, damages, rights or cause of action, present and future.*
I confirm that I will inform The Unruly Mum of any changes to the above information promptly and this must be prior to undertaking any further exercise with The Unruly Mum. *
I am consent for The Unruly Mum to contact me via e-mail. (Your e-mail address will not be shared with anyone without your permission and you will never be bombarded with spam).*

I agree
Should be Empty:

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