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Health Screening Form

Prenatal

Exercising with Baby

Please complete this screening form prior to a class or session with Harris Mind & Body.

 

Please view it as your responsibility to make sure your HMB teacher is fully aware of your current health conditions, so please review this information regularly.

This information is strictly confidential and only used to help us - better help you. 

Please note boxes with a * must be completed.

The form will not submit if a * box has been left empty.

 

Thank You

HMB Team

We need to ask you some additional information to help us best look after you and your baby during your pregnancy. You will notice - much of the form is the same but there is now some extra sections to complete. If you have any questions or concerns please don't hesitate to ask us.

Pregnancy
Health Screening, Health Declaration & Future Goals
Please fill out the following health declaration form in order to participate in our activity.
Please note we never share this information with outside sources, your details are treated strictly confidential. If we need to refer you back to your GP as an example we will ask for your consent.
Services you use or intend to use at Harris Mind & Body (HMB)
Physical Activity Readiness Questionnaire (PAR-Q) - please tick to answer yes
Select an option
Relevant medical history - please tick if relevant to you
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Classes / fitness that you like to do OR have done in the last year
To enable your teacher and/or physio - prepare a suitable programme for you, please tick if relevant

Prenatal section

Have you experienced any of the following: