Antenatal Fitness Screening Form

The information collected in this form will be used only for the purpose of designing an appropriate fitness program for you and will not be disclosed to any third party without your consent.

We reserve the right to request a doctor’s clearance before allowing you to receive personal training with Kate Campbell Fitness.

Please fill out the form as thoroughly as possible.

Name *
Name
Address
Address
Due Date
Due Date
Antenatal History *
Please Ensure the following information is correct. If you have any previous or current medical conditions, injury or disabilities you may need to speak to your GP or Physiotherapist before you attend. Do any of the following apply to you?
Exercise History *
Tick the type of exercise you did regularly before becoming pregnant
How did you hear about Keep Mums Fit *
Informed Consent *
I hereby state that I have read understood and answered honestly the screening questionnaire. During the exercise programme, every effort is made to keep the class safe and minimise the risks whist providing an effective session. I am participating of my own free will and I am aware, as with any exercise programme, there is a risk of injury. I agree to participate in the exercise programme described to me by Kate Campbell and the Kate Campbell Fitness Team I understand that in order for the session to remain safe, alternatives and adaptations will be made throughout. The structure, purpose, benefits and risks of the session will be explained throughout the class, and I understand that I may withdraw from the session at any time. I will inform Kate or the KMF team instructors if any physical / Medical changes occur which may prevent me from exercising safely. If at any time you feel undue pain or excessive discomfort, Stop the activity and inform instructor. I understand that photographs will be taken from time to time during the class for advertising and promotion purposes only, and I agree to having my picture taken.
Terms and conditions *
I have read and agree to the terms and conditions available in the footer of this website