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Movement Classes
One-on-one Training
Timetable
About
Contact

book a session

New Client Pre-Screening

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Personal Details

Full name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Date of birth(Required)

DD slash MM slash YYYY

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Medical Details

Referral(Required)

On referral from Dr (which I have provided today)

I will list details below

Referred by(Required)

Referred for(Required)

Details(Required)

Condition

Date diagnosed

Family history (Y/N)

Other health professionals I am currently working with

Please provide a list of current medications & supplements:

Medication / Supplement

Reason for taking

Medical Pre-Screening

Do you, or have you ever, suffered from any of the following?

Low/High Blood Press

Chest Pain

Respiratory Problems

Angina/Heart Attack

Stroke

Diabetes

Kidney/Liver Disease

Asthma

High Cholesterol

Irritable Bowel Syndrome

Thyroid Issues

Dizziness/Fainting

Pelvic Floor/Bladder Weakness

Glandular Fever

Major Surgery

Please provide notes for any positive responses above:

Do you, or have you ever, suffered from any of the following?

Dislocated Joints

Broken Bones

Headaches

Ankle/Foot Pain

Shoulder Pain

Wrist Pain

Elbow Pain

Back Pain

Hip Pain

Knee Pain

Neck Pain

Back trauma/injury

Tingling/Numb Limbs

Arthritis

Osteoporosis’

Cancer

Pneumonia

Low immunity

Please provide notes for any positive responses above:

Is there any other medical history that may impact upon your ability to exercise or your recovery from exercise?(Required)

Failing to disclose information is at your risk

Yes

No

Details(Required)

Are you, or have you ever, been a cigarette smoker?(Required)

Yes

No

Have you belonged to a gym before?(Required)

Yes

No

Did you enjoy your time there?(Required)

Yes

No

Have you ever had a Personal Trainer before?(Required)

Yes

No

Please list any sports, physical activities, hobbies, or outdoor interests you have been involved in the last 12 months:

(For Females) Do you have children?

Yes

No

How many and ages

Are you currently pregnant?(Required)

Yes

No

If yes, how many weeks?(Required)

Do you currently have, or have you had, menopause?

Have you recently visited a Gynaecologist or Endocrinologist?(Required)

Yes

No

If yes, who?

Have you ever used any of the following health professionals?

Physiotherapy

Osteopathy

Chiropractic

Naturopathy

Homeopathy

Acupuncture

Massage

Craniosacral

Nutritionist

Life Coach

Reiki

NLP

Which Whangarei Health Professionals do you use

Names and Clinics for reference

We use our own network of health professionals that we have a reciprocal relationship with. Are you happy for us to refer you on to any of these as we see appropriate?(Required)

Yes

No

Is there anything else that you feel is important for me to know before proceeding with exercise?

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Train safe. Train hard. Train at Studio 51.

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Movement Classes
One-on-one Training
Timetable
About
Contact

Movement Classes
One-on-one Training
Timetable
About
Contact

Contact

51 Commerce Street
Whangarei 0110

nicci@itsstudio51.co.nz
021 864 446

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