Emily's Class - Screening Questionnaire

Name*

First NameLast Name

D.O.B

Mobile*

Email

example@example.com

Instagram Profile

Facebook Profile

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

When did you loose your baby/child and at which gestation or age?*

Do you have any other living children? If yes how many?*

If you answered yes above please confirm the age of your youngest child?*

Do you leak urine when coughing or sneezing?

Do you leak urine when you run, jump or conduct any other physical exercise?

Have you ever had a prolapse? Please detail.*

Do you have diastasis recti (split of the abdominal muscles)? If yes, please detail.*

Have you ever experienced any of the following?*

Have you had surgery in the last 12 months. If yes please detail.*

Occupation

Have you exercised in the last 6 months? Please detail type and frequency of exercise.*

Where did you hear about Emily's Class?

Name*

First NameLast Name

Mobile*

Relationship*

Many health benefits are associated with regular exercise. For most people physical activity should not pose any hazards or problems. This screening questionnaire has been designed to identify any females for whom physical activity via online classes might be inappropriate.

If your health changes after completion of this questionnaire it is essential that it is brought to the attention of StrongMumsNI immediately and medical advice sought if appropriate.

It is important that you listen to your own body and take each class at your own pace, choosing any adaptations presented in any instance that you need to reduce intensity. You must make the instructor aware of any medical conditions or injuries. If at any time you have any questions, feel unsafe or unwell, you must inform the instructor immediately and discontinue further participation in the class

It is recommended that you consult your GP prior to any exercise programme. The instructions and advice presented are in no way intended to be a subsitute for medical advice.

Any participant in StrongMumsNI Online classes assumes the risk of injury resulting from performing exercises shown. StrongMumsNI disclaim any liability or loss in connection with the exercises and advice contained herein.

I, the undersigned, hereby state that I wish to participate in StrongMumsNI Online Fitness Classes. I realise that my participation in these classes involve potential risk of injury, including but not limited to bodily injury, heart attack, stroke or even death. I also recognise that there are other risks assosicated with exercise and that it is not possible to list every one. I know and understand the risks of exercise, understand that injuries are a possibility and I hereby assume all risks of injury which could occur by participation in these online fitness classes.

My signature also acknowledges my consent to be videotaped, audio recorded and/or photographed during the class and grants StrongMumsNI the sole right to own, use and modify the images and/or recordings for advertising, marketing and media purposes, without any compensation.

Signature*

Date*

Healing Strength Programme / Emily's Class

CONTACT DETAILS

Personal

Medical History

General Information

Next of Kin

Liability Waiver