Prenatal Health & Screening Form

Health Screening Form

Prenatal

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.

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.

Title

First Name

Last Name

Address

Postcode

Phone number 1

Phone number 2

Date of Birth

Occupation

Emergency Contact Name

Emergency Contact Number

How did you hear about us

Physical Activity Readiness Questionnaire (PAR-Q) - please tick to answer yes

Has your doctor ever said that you have a heart condition & that you should only do activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs for your blood pressure or heart conditions?

Do you know of any other reason why you should not do physical activity?

If you have answered yes to any of the above questions it is our request and recommendation that you speak with your doctor by phone or in person before embarking on any new physical activity.

If you answered yes but are confident you have already spoken with your doctor and he/she feels you are able to proceed please take a moment to add some additional details here - please know this is to help us look after you to the best of our ability:

Select an option

I have answered above

My answer is NO to all in this section

If you have had surgery in last 12 months please add some additional information here:

If you would like to add additional information please do so here:

Please provide a list of medications if you feel it could be helpful for us to know.

To enable your teacher and/or physio - prepare a suitable programme for you, please tick if relevant

I have a hearing impairment

I have a visual impairment

I have difficulty getting down to the floor

I have difficulty weight bearing

I find balancing a challenge and would benefit from addtional support

None of these apply to me - as I am able to do most things.

Any additional information that you would like to add to assist your comfort levels in a class setting?

Please list any other hobbies

What are your fitness, health and wellbeing goals?

Anything else that you would like to notify us about?

Prenatal section

What is your due date?

How many weeks pregnant are you

Who is your GP / Midwife overseeing your pregancy

Hospital (birth or routine / emergency)

How many babies are you carrying

Have you been told to not exercise?

Do you have other children?

Type of delivery

Have you been exercising prior to becoming pregnant

If yes to any of the above, please provide more detail:

Is there anything else in your medical history that you feel could effect your ability to exercise?

What concerns your pregnancy / birth?

How do you spend most of your day (at work / work from home / other) ?

What goals would you like to achieve whilst participating in physical activity - linked to your pregnancy?

A consent form/section is designed to inform you about what activities you are going to be involved in, to inform you of any risks and to give you the chance to ask any questions.

Please confirm you have read and agree to all the points above for your consent.

Yes - I give my consent.

I agree to the terms & conditions - this includes our 24 hour cancellation policy where my credit will be stored with HMB but there are no refunds.View terms of use

I want to subscribe to the newsletter. Please note we don't send these very often.

We also recommend you like and follow our page on Facebook - search Harris Mind & Body - or click here

To the best of my knowledge I will never knowingly attend HMB The Atrium for an appointment or class if I have any symptons of Covid 19 or whilst I have been asked to isolate.

I am over 18 years old

Yes

No - in which case a parent / guardian will also need to sign and date this form on your behalf.

Initials

Date

Date (parent / guardian if under 18)