Tailored - pregnancy and post natal exercise classes

Specialist - pregnancy and post natal personal training

and Beyond - fitness for working mums and dads

Womens registration form

Course: * Required
First Name: * Required
Last Name: * Required
Date of Birth: * Required
Email address: * Required
Confirm email address: * Required
Address1: * Required
Address2:
Town: * Required
County: * Required
Postcode: * Required
Mobile number: * Required
If pregnant, please state your due date:
If you have had a baby within the last 12 months please state when:
Please state type of delivery:

Emergency contact details.

Name: * Required
Mobile: * Required

Medical Questionnaire.

Has your doctor ever said that you have a heart condition? YES NO
If YES, please give details:
Do you feel pain in your chest when you do any physical activity? YES NO
In the past month, have you had chest pain when you were NOT doing physical activity? YES NO
Do you lose your balance because of dizziness or do you ever lose consciousness? YES NO
Do you have a back, pelvic or other joint problem that could be made worse by a change in your physical activity? YES NO
If YES, please give details:
Do you suffer from raised blood pressure? YES NO
If YES is this pregnancy related and how is it being treated?
Do you suffer from diabetes? YES NO
If YES, is it pregnancy related and how is it being treated?
Do you suffer from asthma? YES NO
If YES, how do you control it?
Do you know of any other reason that could affect your participation in exercise? YES NO
If YES, please give details:
Are you a regular exerciser? YES NO
If YES, please give details:
Do you intend to do any other exercise in addition to this programme? YES NO
If YES please give details:
Have you had your post natal check up? YES NO
Was everything satisfactory in your post natal check up? YES NO
If NO, please give details:

Informed Consent

A group fitness programme has been designed for you, taking into account your health and activity levels. It may involve cardiovascular work, core stability training, and a mixture of indoors and outdoors activity.
All activities will be explained and demonstrated where necessary. Please feel free to ask questions about any part of the programme. Any exercise programme carries with it an element of risk. This programme is designed in such a way as to minimise the risk whilst conveying maximum training benefit to assist you in achieving your goals.
Please inform me if for any reason you should not participate in a particular exercise, or of any injury that you have which may be aggravated by exercise. If at any time during a class you feel undue pain or excessive discomfort, you should stop the exercise and inform me.
I agree to take part in the Zest4lifeUK course that I have signed up for and I understand that the programme will change and progress over the 10 weeks. The nature, purpose, risks and benefits have been explained to me.
I warrant that I have made a full and correct disclosure of my health status on the Medical Screening Questionnaire, that my status has not changed since the aforementioned disclosure and that I am not aware of any adverse medical condition in myself which Zest4lifeUK would expect me to reveal.
I understand that Zest4lifeUk does not bear any liability for personal injury however caused to any persons, including but not limited to myself as a result of my participation in this programme. Zest4lifeUK recognises that liability as a result of negligence cannot be excluded.
Participant’s name:

By checking this box you agree to zest4lifeuks consent form and confirm that all answers are correct.
Witness name:

By checking this box you agree to zest4lifeuks consent form and confirm that all answers are correct.
Date:
How did you find us: * Required
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