Mums-HIIT Pre-Screening Form
Pre-screening form for Mums-HIIT small group classes.
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua & Barbuda
Bosnia & Herzegovina
British Indian Ocean Territory
British Virgin Islands
Central African Republic
Cocos (Keeling) Islands
Congo - Brazzaville
Congo - Kinshasa
French Southern Territories
Heard & McDonald Islands
Hong Kong SAR China
Isle of Man
Macau SAR China
Northern Mariana Islands
Papua New Guinea
São Tomé & Príncipe
South Georgia & South Sandwich Islands
St. Kitts & Nevis
St. Pierre & Miquelon
St. Vincent & Grenadines
Svalbard & Jan Mayen
Trinidad & Tobago
Turks & Caicos Islands
U.S. Outlying Islands
U.S. Virgin Islands
United Arab Emirates
Wallis & Futuna
What is your occupation? (Full time Mum, teacher, lawyer, carer etc)
Leighton Buzzard (evening)
Leighton Buzzard (daytime)
Date of your last delivery:
Type any births you have had, please put your latest experience first (assisted, vaginal, C-section):
Are you breastfeeding?
How was or how is your post natal healing going? Have you experienced any prolonged post natal bleeding? How is your C-section, tears, episiotomy?
Please provide some details of your pregnancies 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? Please let me know how long ago these were.
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 of anything ticked above (for example: degree of tearing/ type of prolapse etc)
How would you describe your pelvic floor health?
Do you have 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?
Is there anything else you think I should know? For example are you on any medication, experience depression or have any old injuries?
Do you have a history of exercise? Running, Zumba, Pilates, Weight Training etc.
How would you rate your stress levels? 1 being 'not stressed at all', 10 being 'I feel high levels of stress all the time!'
Please consult your GP or a Women's Health Physiotherapist before you start your new regime. Drink lots of water or an isotonic drink throughout and after your workout. Please wear comfortable clothing that will enable you to exercise without restriction. The sessions will last 30 mins including a warm-up and stretch.
RISKS AND DISCOMFORTS OF TRAINING:
Bodies react differently to exercise and cannot be predicted. Should you feel unwell or unsure please inform me (Sarah Pearson)
. I cannot be held responsible for any injuries that may occur.
All information acquired during and prior to sessions will be treated as privileged and confidential information. This form is stored in a password protected site and abides all current data protection laws. PLEASE NOTE you ca add yourself to my mailing list below - you can opt out at any time and I promise not to spam you!
You are more than welcome to bring along your children to selected classes, but they are your responsibility and I (Sarah Pearson) cannot be held responsible for your child/children. Please also be aware that we are in a gym style environment! No child care is provided.
Please bring a mat/throw or similar to lay your child on and their favourite toy often helps!
Please be careful when parking your car. Please park in the allocated spaces ONLY at The Studio - there is an over flow area with ample spaces.
COMING AND GOING:
There are limited spaces at both venues for buggies so I strongly suggest you carry your child.
All sessions must be paid for in advance directly to me (Sarah Pearson). Payment can be made via BACS or PayPay, all clearly labelled with your name, contact number and date of first session. Please ask for the specific payment details if you need them.
Please let me know if you cannot attend a class. If you are unable to do so, please be advised the session
be rescheduled or used against a future course.
PLEASE NOTE THAT NO REFUNDS ARE GIVEN.
I agree to the terms laid out above (required)
I understand that childcare will not be provided and my child/children's safety is my own responsibility
Please add me to the Pear Projects mailing list
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