Pre-Activity Questionnaire
To ensure safe and effective exercise prescription for our clients, it is a requirement that all Go Mum! Group Fitness clients complete a Pre-Activity Screening Questionnaire prior to participating in an exercise programme. All information disclosed in this form will be treated with the strictest confidence and used to ensure safe exercise prescription.

Client Agreement:

By submitting this form, I acknowledge and agree that my participation in Go Mum! Group Fitness classes will be on the following conditions:

• All information in this form has been completed accurately and fully
• I have advised of all injuries and illnesses that I have or have had, all medications I am taking and any other conditions that may affect my participation in physical exercise
• I agree to inform the instructor, prior to the commencement of class, of any changes to my physical condition (illness, injury or medications)
• I agree to follow the directions of the instructor at all times and acknowledge that failure to do so may expose me to risk of injury
• I will advise the instructor if I begin to feel unwell or am in discomfort during the class
• I have read the contra-indications sheet appended to this form
• Participation in Go Mum! Group Fitness Classes/Personal Training Programmes requires physical exertion and is conducted at my own risk
• I acknowledge that when bringing children to class that they will remain under my supervision and at no time are the responsibility of Go Mum! Group Fitness
• I am providing Go Mum! Group Fitness and it’s instructors with personal information and that this information will only be used to prescribe appropriate exercise, contact me in relation to my participation in Go Mum Group Fitness services and to inform me of special offers that may be of benefit to me.

Full Name *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Phone Number:
Your answer
Email address: *
Your answer
Street
Your answer
Suburb *
Your answer
State
Your answer
Postcode *
Your answer
Children's first names
Your answer
Do your children have any food allergies?
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Phone:
Your answer
How did you hear about us? *
Are you currently undertaking any exercise? *
Please list the types of exercise, frequency and intensity below:
Your answer
Did you exercise during pregnancy? *
Please list the types of exercise you did during pregnancy:
Your answer
Did you participate in regular physical exercise prior to having children? *
What types of regular exercise did you do before children?
Your answer
What are you hoping to achieve by accessing the services of Go Mum! Group Fitness? (tick all that apply) *
Required
Considering the goals you selected above, detail one (1) specific health/fitness goal you would like to achieve: *
Your answer
Have you ever had or currently suffer from any of the following? (mark all that apply) *
Required
Is there any other physical reason or medical condition which could prevent you from undertaking an exercise program, or that you are concerned about? *
Your answer
Please list any operations you have had (write NIL if not relevant): *
Your answer
Are you currently on any medication? (write NIL if not relevant): *
Your answer
When were you last assessed for abdominal separation? *
Would you like our trainer to do a quick check to see where your abdominal separation is at? *
Are you currently pregnant? *
During your most recent pregnancy, did you experience any of the following? (tick all that apply) *
Required
Are you currently experiencing any of the following: *
Required
FOR PREGNANT AND POSTNATAL CLIENTS: I confirm that I have obtained clearance from my GP to participate in an exercise programme (for postnatal clients this will usually be the 6 week postnatal check up) and any findings or recommendations provided by the GP at that check-up have been detailed in this form.
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