1-2-1 Personal Training - Health Screening Questionnaire (Pelvic Floor)

Name *

First

Last

Date Of Birth *

Email Address *

Address *

Mobile Phone Number *

Occupation *

Approximate number of hours worked per week (if applicable)

GP Address

Health History

● Please delete either “Yes” or “No” to each question. Put an “X” in the appropriate column.
● If you answer “Yes” to any question, please give details in the spaces provided as appropriate.

1) Do you have or have you ever had a known heart condition e.g. previous heart attack, stroke, abnormal ECG, palpitations, murmurs? *

Yes
No

2) Is there a history of heart conditions in your family? *

Yes
No

3) Do you ever feel pain in your chest when you exercise or do physical activity? *

Yes
No

4) Do you ever feel pain in your chest when you are not exercising or not doing physical activity? *

Yes
No

5) Do you have, or have you ever had a bone or joint condition that could be made worse by exercise or that could prevent you from exercising? *

Yes
No

6) Are you currently taking any prescribed medication? *

Yes
No

If yes please enter your medication details in the box at the bottom of this form

7) Do you know of any other condition that might be reason for you not to exercise? *

Yes
No

8) Do you have any other medical conditions not mentioned (e.g. Asthma, Diabetes, Arthritis, Gout, Epilepsy, Hernia, Dizziness, Circulation problems, Ulcer)? *

Yes
No

9) Do you have, or have you ever had high blood pressure? *

Yes
No

10) Do you have an injury or illness that could be made worse by exercise?

Yes
No

11) Do you ever experience pain in any of the following areas: neck, shoulders, arms, wrists, ankles or knees? *

Yes
No

If you answered YES to any of the above in this section, please state the question reference number and the details below.

12) Are you participating in any form of exercise or physical activity at the moment? *

Yes
No

If you answered YES to the above question. Please outline what you are doing? How many times a week and for how long do you do this activity or activities? On a scale of 1-10, how intensive is the activity?

13) Pelvic floor symptoms: please use the box below to give as much info as you can about what symptoms/pain/issues you're experiencing with your pelvic floor at the moment. And, then we'll discuss these in more detail during our first appointment together

Informed Consent *

I Confirm to the details below

I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with Claire Mockridge or her staff, my Doctor and/or healthcare team. I understand that any exercise program has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in personal training activities, and will immediately discontinue any activity if I feel any symptoms of distress or discomfort, and will notify my instructor.

I understand and acknowledge that the instructors of Claire Mockridge are not Health or Medical Practitioners and therefore can not diagnose or treat individual health or medical problems. All such questions and concerns should be directed to my own Doctor and/or Women's Health Physio, and I agree to do so.

1-2-1 Personal Training – Health Screening Questionnaire (Pelvic Floor)

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