Mums-HIIT pre screening form
Pre screening form for Mums-HIIT @ Chesham and Leighton Buzzard.
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Interested in the class held at;
Date of delivery:
Type of delivery (assisted, vaginal, C-section):
Are you breastfeeding?
How is your post natal healing going? Have you experience any prolonged post natal bleeding? How is your C-section, tears, episiotomy?
Please provide some details of your pregnancy and post natal period including any complications, illnesses, reasons to visit your doctor or an other health practitioner, including massage, physiotherapy etc.
Have you had any other children or pregnancies?
Check All That Apply
Symphysis Pubis Dysfunction (pain in the centre of pubic area)
Sacrum pain (pain in very low/mid back or top of buttocks)
Bleeding during or after exercise or any unexplained bleeding
Carpal Tunnel Syndrome (Wrist, finger, hand forearm-pain/numbness or tingling)
High/low blood pressure or episodes of faintness, dizziness or breathlessness
Upper back/neck/shoulder pain
Coccyx damage or pain
Separation of your abdominal muscles (diastasis)
Incontinence (urinary or faecal)
Prolapse (uterine, bladder, rectum, vaginal)
Breast health/breast feeding issues/mastitis
Did you have an Epidural during birth?
Nerve damage during birth (pudendal)
C-section wound discomfort or slow healing or ongoing numbness
Anaemia or taking iron tablets
Joint or muscle pain
Episiotomy cut or tears (degree if known)
Notes or details for anything ticked above (for example: degree of tearing/ type of prolapse etc)
How would you describe your pelvic floor health?
Have you ever suffered a prolapse or pressure in the vagina/rectum? Do you leak urine when you exercise, sneeze, laugh, cough, or find it hard to hold in gas or urine?
Has your doctor ever advised that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when doing physical exercise? Do you suffer with asthma?
Is your doctor currently prescribing drugs for your blood pressure or a heart condition?
Consult a GP or Women’s Health Physio before you start your new fitness regime. Drink lots of water throughout and after your workout. Please wear comfortable clothing that will enable you to exercise without restriction, including a good sports bra! The sessions will last 30 minutes in length, including a warm up and stretch.
Risks and discomforts of training:
As with all exercise there is a risk of changes or injuries occurring during or following exercises including abnormalities in blood pressure/heart rate. Should you feel unwell or unsure please inform me (Sarah Pearson) IMMEDIATELY. I cannot be held responsible for any changes or injuries that may occur.
All information acquired during and prior to sessions will be treated as privileged and confidential information. You are free to leave the training session at any time but that session will be counted as ‘used’.
You are more than welcome to bring along your babies but they are your responsibility and I (Sarah Pearson) and the staff of the venue can not be held responsible for your child/children. Please also be aware that we are in a gym style environment and that those children who are crawling/walking should not attend (allowing you to enjoy the class). No child care is provided.
PLEASE BRING A MAT OR SIMILAR TO LAY YOUR CHILD ON AND THEIR FAVOURITE TOY!
All sessions must be paid for in advance directly to me (Sarah Pearson). Payment can be made via BACS, paypal, cheque or cash all clearly labelled with your name. Please ask for the specific payment details.
Please be careful when parking your car, please avoid blocking any entrances and where possible park in the town centre at the Bagnall Centre (Chesham) and in the allocated spaces only at The Studio (Leighton Buzzard). There is space for only 4 buggies at the Bagnall Centre so I strongly advise you carry your child or bring them in a car seat.
Unfortunately no refunds can be given and this is a 6 week course… I know that when you are a Mother many things can mean you have to cancel last minute - if this happens please let me know as soon as possible so I can review the class content as quickly as possible. Please feel free to opt for the ‘flexi’ option of 5 out of the 6 sessions for £50.
No refunds are given. By submitting this form you are agreeing to all of the above.
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