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HER NEXT CHAPTER | GET A GRIP
Health Questionnaire & Exercise Consent
Personal Details
Date of birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Full name
*
First Name
Last Name
I confirm I am 18 years or over
*
Yes
Email address
*
example@example.com
Mobile number
-
Country Code
-
Area Code
Phone Number
Programme Acknowledgement
I understand that exercise involves some risk of injury. I agree to exercise within my abilities, use appropriate equipment safely and stop exercising if I experience pain, dizziness, chest discomfort or unusual symptoms. I understand that I should seek appropriate medical advice when necessary.
*
I have read and understood the exercise safety information above
I acknowledge the programme includes the GET A GRIP 12-week SELF-LED gym strength programme from Her Next Chapter (by CooperCoreFitness) and I understand it is a general pre-written training resource, not individualised coaching, a personal training service, medical assessment, supervision, or real-time exercise monitoring.
*
Yes
I confirm that I have completed this questionnaire honestly and understand that I am responsible for following the programme independently and exercising within my own abilities
*
Yes
Health Screening
Are you currently pregnant?
Yes
No
Have you given birth within the last 12 months?
No
Yes, within the last 12 weeks
Yes, between 12 weeks and 6 months ago
Yes, between 6 and 12 months ago
If applicable, please provide further details including how many weeks pregnant or postpartum you are, and whether you have received any relevant medical advice
Do you have any medical conditions we should know about?
*
No
Yes
Not sure
If yes or unsure, please provide further details including any relevant medical advice you have received
Do you currently have any injuries, pain or physical limitations that affect your ability to exercise safely?
*
No
Yes, but I can exercise comfortably without restrictions
Yes, and it affects my ability to exercise
I’m unsure
If yes or unsure, please provide further details including any relevant medical advice you have received
Have you experienced unexplained dizziness, fainting or blackouts particularly during or after physical activity?
*
No
Yes
Not sure
Do you experience unexplained chest pain or unusual breathlessness during exercise?
*
No
Yes
Not sure
If yes or not sure, please give brief details
Have you ever been diagnosed with a heart condition, high or low blood pressure, or any other circulatory conditions?
*
No
Yes
Not sure
If yes or not sure, please give brief details
Do you currently experience or have you previously experienced any of the following
*
Pelvic floor symptoms
Prolapse symptoms
Abdominal separation
Pelvic girdle pain
None of the above
If yes or unsure, please provide further details
Are you currently pregnant, have you given birth in the last 12 months, or are you currently recovering from childbirth?
*
Currently pregnant
Given birth within the last 12 months
Recovering from childbirth, including more than 12 months ago
None of the above
If you are pregnant or recovering from childbirth, please seek appropriate advice from your midwife, GP, or pelvic health physiotherapist before starting where needed. This programme does not include pregnancy or pre-postnatal specific exercise modifications. This doesn't mean pregnancy or being postpartum automatically excludes someone. It simply makes the limitations of the programme clear. Another programme may be more suitable.
Consent and Privacy
HER NEXT CHAPTER Privacy Notice
Your privacy matters to me. Her Next Chapter, operated by Coopercorefitness, collects personal information through this questionnaire, including contact details, medical history, injuries and relevant women's health information.
How your information is used
Your information is used to review any health considerations relevant to participating in GET A GRIP and to manage your enrolment. This questionnaire is not a medical assessment or confirmation of medical clearance to exercise.
How your information is protected
Your information is treated confidentially and processed using services such as Jotform, Payhip and TrueCoach, where applicable. Access is limited to those who need it to administer your programme. Your information will not be sold or used for marketing without your permission. It will be retained only as long as necessary for programme administration and applicable legal requirements.
Your rights
You can request access to, correction or deletion of your personal information, or withdraw your consent, subject to applicable legal requirements. For privacy enquiries, please contact: Coopercorefitness@gmail.com. You can also raise concerns with the UK Information Commissioner's Office (ICO).
I have read the privacy notice and explicitly consent to my health information being processed for the purposes explained above.
*
I consent
Would you like to receive occasional fitness tips, programme updates, and news from Her Next Chapter
Yes please!
Submit health questionnaire
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