General Personal Training Questionnaire General Personal Training Questionnaire Full name... * Home address... * Post code... * Phone number... * Emergency contact name and number... * Email Address... * Medical history and conditions-please tick all that apply to you... Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? Do you feel pain in your chest when you do physical activity? In the past month, have you had a chest pain when you were not doing physical activity? Do you lose your balance because of dizziness or do you ever lose consciousness? Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? Have you ever had any major surgery or trauma to your body? Is your doctor currently prescribing medication for your blood pressure or heart condition? Do you know of any other reason why you should not do physical activity? Could you be pregnant or have you had a baby in the past 6 months? If yes, please state how you gave birth in the section below. (Vaginal, c-section) Post natal questions-please tick those that apply to you... Could you be pregnant or have you had a baby in the past 6 months? If yes, please state how you gave birth in the section below. (Vaginal, c-section) Were you given an epidural during birth? Did you suffer pre-eclampsia? Did you suffer Nerve Damage during birth (Pudenal)? Did you have an episiotomy cut or painful perineum tears (degree if known)? Are you suffering C-Section wound discomfort, slow healing or ongoing numbness? Are you suffering the after effects of Gestational Diabetes? Are you experiencing bleeding during or after exercise or unexplained bleeding? Are you still breastfeeding? Are you experiencing any breast health issues? Do you lose urinary or faecal control when laughing, sneezing, coughing or jumping or moving quickly? Or leak without warning? Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Do you currently or have you ever needed to wear incontinence pads? Do you have separation of your abdominal muscles (diastasis recti)? Do you experience pain inside or at the joints of your pelvis? Are you experiencing Symphysis Pubis Dysfunction (SPD – pain in the central pubic area) Do you experience sacrum or SIJ Pain (pain in the very low mid back area - top of buttocks)? Do you have Carpal Tunnel Syndrome (wrist / finger / hand / forearm pain / numbness or tingling)? Do you suffer Upper back/Neck/ Shoulder Pain? Do you suffer Knee Pain (inside, outside, front, back)? Do you suffer buttock, piriformis pain, sciatica or low back pain? If you have answered YES to any of the above questions, please give more information below... In your own words, what are your goals? What is your reason for signing up to train with Julie Bartlett? * Please confirm: Please tick here to show you accept and understand the below: • In accordance with the new GDPR regulations of May 2018 clients have the right to request to see any personal data that Movement-for-life have on record. This data is held for insurance and medical purposes and is never given to any third-party organisation. • Clients recognise that technology is a powerful tool within marketing and sharing amazing results with members of the public. Therefore, clients are sometimes in photography, filming and social media. Unless otherwise informed, movement-for-life has permission to display media such as, photos and videos or clients on face book/website and other marketing sources. • Clients understand that any comment they say/write/film can be used as a testimonial to promote movement-for-life. This includes photos as well. Submit
