RB Fitness joining form

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Physical Activity Readiness Questionnaire

This form includes several questions relating to pregnancy and birth as I run a lot of pre/postnatal specific classes.

Please skip past these questions if you are not postnatal, but still ensure you complete the form with any relevant health information.

ALL women are welcome at RB FITNESS classes.

Name *

Email *

Address *

Phone number *

Emergency contact number *

Emergency contact name

Are you currently pregnant

Yes

Clear selection

If Pregnant, how many weeks?

If postnatal, date of postnatal check up with most recent child

YYYY

Number of children and their ages

Please select any interventions or injury during labour and delivery

Ventouse

Forceps

Episiotomy

Perineal Tear

Coccyx Damage

Type of delivery (select all that apply)

Vaginal

Elective C section

Emergency C section

Are you breast feeding?

Yes

Clear selection

Are you / have you experienced any of the following?

Pelvic Girdle Pain

Lower back or hip pain

Urge to go to the toilet more frequently

Incontinence (bladder or bowel)

Feeling of heaviness or bulging in the pelvic area

Core weakness

Pain during or after sex

Headaches

Dizziness or Fainting

Low Mood or depression

Fatigue or muscle weakness

Sciatic Pain

Pins and needles or poor circulation

Low or high blood pressure

Covid-19

Diastasis Recti (abdominal separation)

If you checked any boxes in the previous question, are you suffering with these issues currently?

Yes

Clear selection

Please detail any other injury or symptoms relating to your pregnancy or labour including whether you have had medical / physiotherapy treatment for any issues

Previous medical history (not relating to child birth)

Is there anything else that you feel may be important for us to know to support your health journey?

How often do you currently exercise?

none

1-2 times a week

3+ times a week

I have not yet returned to any exercise post baby

No formal exercise but I am active (walking, etc)

Clear selection

Do you have any goals that you would like RB fitness to help you achieve? (anything goes here!)

In order to keep you up to date with class information, we may need to contact you from time to time. In order to comply with GDPR we would need your consent to contact you. Please select which ways you are happy to receive communication from us. You can opt out at any time by contact me direct. *

Text

Social Media

Required

How did you hear about us?

Previous attendance

Social Media

Other marketing (leaflets / flyers etc)

Word of Mouth

Recommendation from medical professional (HV, midwife, etc)

Other:

Clear selection

Sometimes we take pictures to assist in marketing of classes. Please confirm you are happy for this *

Yes

Please confirm that you have read and understood the terms and conditions *

Yes

Required

I understand that whilst RB Fitness will endeavour to ensure the safety of all participants, exercise does come with some risks and RB Fitness will not be held responsible for any injury or damages incurred to yourself, or your children. I agree to listen to my body and inform the instructor of any future injuries to ensure I remain safe to exercise at all times. *

Yes I understand and accept the above

Submit

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