The Mama Movement Health & Fitness Screening Form

Basic Information 

Do you currently or have experienced any of the below in the past 12 months

High or Low blood pressure?
History of Heart Problems?
History of respiratory illness or asthma?
Lower Back Pain or Sciatica?
Coccyx damage or pain?
Pain or limited movement in any joint?
Diabetes
Epilypsy
Are you on any medication? If yes, please specify
Any recent illness, injury or surgery ? If yes, please specify
Have you any training or exercise experience?

IF Yes, What type of training or sport have you been doing ?

Do you experience leaking? Leaking urine when cough/sneeze/exercise
Do you have a prolapse? (e.g. a bulge or feeling of heaviness, discomfort, pulling, dragging or dropping in the vagina)

For Pregnant Mamas 

How many weeks pregnant are you?

Are you carrying more than one baby?
Are you experiencing Morning Sickness?
Gestational diabetes?
Pelvic or Gynaecologic Pain? If yes, please specify.
Spotting or bleeding during pregnancy?
History of miscarriage or pre term labour? If yes, please specify

MAMA TO BE CLASS DAYS

Class Day Preference

Postpartum Mama

How many weeks / Months postpartum are you?

Did you have a vaginal delivery or a c-section?

Have you any pelvic pain/ gynaecologic pain/pressure? If yes, please specify.

Have you experienced any leaking of urine/ bowel movement / straining or difficulty passing urine , gas or a bowel movement ? 

If postpartum, have you been signed off by your doctor to resume training?
Have you seen a pelvic floor physio?

Health details or anything else your instructor needs to know:

POSTPARTUM MAMA 1 - RETURN TO EXERCISE CLASS PREFERENCE

Class Day Preference

POSTPARTUM MAMA 2- RETURN TO HIGHER INTENSTITY CLASS PREFERENCE

Class Day Preference

Photo Release Form for The Mama Movement 

I hereby grant The Mama Movement  the right to photograph myself and my dependent and use the photo and or other digital reproduction of myself and my dependant for publication and advertising processes, whether print, digital or electronic publishing via the Internet.

Signature of participant of The Mama Movement / Parent of dependant

The Mama Movement strongly recommends that you consult with your doctor before beginning any exercise program. You should be in good physical condition and be able to participate in the exercise. The Mama Movement is not a licensed medical care provider and represents that it has no expertise in diagnosing, examining, or treating medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition

Liability Release Form for The Mama Movement

I                                     , ACCEPT ALL responsibility for my own person and my dependant, should an injury occur in any The Mama Movement Class. I assume all financial responsibility for any medical treatment necessary as a result of an injury during class. The undersigned, by signing this waiver of claim and release of liability, acknowledges that there are certain inherent risks associated with an exercise class, any of which could result in property damage or bodily injury. In consideration for the consent and right given to the undersigned to participate in exercise classes with The Mama Movement, and with full understanding of the inherent risks involved, the undersigned does, by signing below, expressly assume all risks of any nature whatsoever and hereby releases and forever discharges The Mama Movement and its employees and sub-contractors from any claim or liability of property or bodily injury of any nature whatsoever arising out of The Mama Movement’s operation, and the undersigned acknowledges full and total personal insurance responsibility while participating with The Mama Movement.

Signature of participant of The Mama Movement / Parent of dependant

I consent that The Mama Movement holds my personal data for the purpose of my safety in their fitness classes

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