Postnatal Health & Screening Form

Health Screening Form

Postnatal

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 after 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

Services you use or intend to use at Harris Mind & Body (HMB)

Physiotherapy

Pilates Mat Group Classes

Pilates Reformer Group Classes

Pilates Studio Group Classes

Pilates Clinical Group Classes

Tai Chi Group Classes

Private Pilates Session

Sports Massage

Reflexology

Podiatry

Cranio-Sacral & Myofacial Release

Nutrition

Women's Health Specialists

HMB Training School - L3 Diploma in Instructing Pilates Matwork - certifed by HMB & Active IQ

HMB Training School - L3 Award in Supporting Pre and Postnatal Clients with Exercise & Nutrition - certified by HMB & AIQ

HMB Training School - L3 Award in Designing Exercise Programmes for Older Adults - certified by HMB & AIQ

HMB Online Exercise Videos - rent for 24 hours or monthly

HMB Online Shop - Neals Yard Products

HMB Online Shop - Clothing

HMB Online Shop - Jewellery

HMB Online Shop - Exercise Equipment

HMB Online Shop - Grip Socks

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

Relevant medical history - please tick if relevant to you

Hypertension

Angina

Heart Problems

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Type 1 Diabetes

Type 2 Diabetes

Obesity

Parkinson's Disease

Alzheimers

Stroke

Depression / Anxiety

Osteoarthritis

Osteoporosis

Low Back Pain

Arthritis

Rheumatoid Arthritis

Epilepsy

Recent Surgery

Joint Replacements

Other

NONE

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.

Perception of your current fitness out of 10

Motivation towards your fitness out of 10

Classes / fitness that you like to do OR have done in the last year

Pilates Mat

Pilates Reformer

Pilates Studio

Pilates Clinical

Tai Chi

Yoga

Gym / Weights

Gym / Cardio

Running

Walking

Cycling

Dance

Sports Specific

Other

None

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?

Postnatal section

Have you had the all clear from your GP / Midwife to return to exercise

Have you been told to not exercise?

What date was the delivery

Did you have a natural delivery or c-section

Did you have an episiotomy

Are you breastfeeding

Are you up a lot during the night

Have your abdominals been tested for Diastsis Recti (seperation of the abominal muscles)

Have you noticed a specfic weakness in your pelvic floor (incontinence)

Whats a typical day at the moment

Is there anything else you feel would be useful for your teacher / physio to know in relation to this postnatal period or anything else

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.

Consent

I understand that my participation in exercise at HMB may involve: mat based exercises, Pilates, use of small props, weights and possibly the use of large pieces of Pilates equipment (reformer etc).

I understand that I may be advised to do some exercises at home to increase the benefits of my programme.

I understand I may be advised on some gentle cardio to support the benefits of my programme and to assist in my overall health- such as walking, jogging, swimming - something that best suits me.

I understand that increasing my daily activity levels - has a huge benefit to my overall health.

I understand that eating a healthy balanced diet - has a huge benefit to my overall health

I understand that the health of my mind and body have equal value and that 10 minutes of time to myself a day to relax or stimulate my mind by being creative or even doing a crossword - has a huge cognitive benefit to my health.

I understand that the team at Harris Mind & Body (HMB) Health & Wellbeing - can help me with all of the above.

I understand my participation in any aspect of health and wellbeing with HMB - is voluntary

I understand that there is some risk of injury or physical reaction when I participate in any activity. Such as stress on my musculoskeletal system and cardiorespiratory system.

I understand that HMB will do all that they can to prevent or minimise such risks.

I understand that I also need to do all that I can to prevent or minimise such risks by ensuring all my information is correct and updated at all times and that I adhere to all HMB guidleines.

I understand that the information obtained from me to HMB will be used by staff only, to eveluate my progress and other internal planning / matters.

I understand my information will be stored safely and as strictly confidential. My details will not be shared with any 3rd party organisation.

I understand that if a HMB staff member feels that I need to be referred (to a Dr / Consultant as an example), my consent to do so will be requested.

I have the right to ask further questions before signing this form, so I complete and sign this form satisfied and voluntarily give my consent.

I hereby fully and forever release Harris Mind and Body (HMB) and all staff members from all cliams, demands, damages, rights of action, present and future therein.

I confirm all the information that I have provided is true, correct and detailed where relevant.

I understand that I know my body best and if at any point I feel uncomfortable, fatigued, strained or any pain - that I can stop exercising immediately and at any point

I will continue to communicate with my HMB teacher / physio

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

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

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

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)

Name

Qualified HMB Teachers

“Look for the butterfly when choosing your Pilates teacher”

All our teachers have exclusive permission to use our HMB Teachers Logo

Click on the teachers name to find out more (in alphabetical order)

Health Screening Form

Postnatal

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.

Postnatal section

Qualified HMB Teachers

“Look for the butterfly when choosing your Pilates teacher”

All our teachers have exclusive permission to use our HMB Teachers Logo

Click on the teachers name to find out more (in alphabetical order)

Health Screening Form

Postnatal

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.

Postnatal section