Family Form

Completing this form means we can save time during our first session and it constitutes all the paperwork we’ll need to do - hence why it’s very thorough. Paperwork is never anyone’s favourite activity, so thank you in advance for taking the time to fill this out to the best of your ability as it will help us prepare in advance to give you the best possible service.

Please choose one person to fill out the section ????

The PAR-Q Form is a health screening document designed for individuals about to take part in physical activity. The questionnaire will identify health issues and recent injuries, illness, ailments and cardiovascular conditions that require my attention before taking part in natural movement training. 

It’s a quick and effective way of screening people about to participate in physical activity of any kind to ensure you are safely able to take part without risk to yourself. 

All information is treated in strict confidence and if you have any problems please contact us.

Note • Please refer to the Universal Pain Assessment tool when measuring your current pain level.

Thanks,
Billy & Frances

Choose ONE Person To Fill Out This Section:
(e.g. cycling, walking to work, gym, classes)
What sports do you do and at what levels.
Note your short and long-term goals; don't be afraid to write down anything you'd like to achieve no matter how out of reach it seems!
Write down which dates and times you are looking to book in and I will see if I can fit you in around that time. I work occassional Sundays and early evenings
Payment Method: *
Please note that payment in full for packages is required at the end of the first session
Do you need a receipt? *
You'll be sent both an Invoice and Payment Received via email for your records
How did you hear of Movementum?
Personal Details
Date of Birth:
Date of Birth:
Pain & Injury Form
Describe the reason for your visit (e.g if it's for a specific injury, chronic pain etc).
Do you have or have you ever had: *
Please describe any notable injuries, operations and accidents; also note if you are currently injured.
Note down any conventional or alternative treatments you've had.
How do you rate your pain today?
Please refer to the Universal Pain Assessment Tool
Please describe any in the past or in recent history.
Whether you were delivered naturally, via C-Section, forceps etc. If you don't know, please leave blank.
e.g falling off a bike and hitting your head, if you wore braces to straighten out your teeth, anything you can remember
Whether it was unassisted, a C-Section, forceps, induced etc
Day-to-day I feel stressed:
Day-to-day I have a lot of energy:
My work shoes are uncomfortable:
My job is stressful:
Do you walk your dog on the same side most days?
Do you carry a bag mainly on one shoulder?
Do you sleep on the same side of the bed most nights?
Physical Activity Readiness Questionnaire
Has your doctor ever said that you have bone or joint problems, such as arthritis that has been aggravated by exercise or might be made worse with exercise? *
Do you have high blood pressure? *
Do you have low blood pressure? *
Do you have Diabetes Mellitus or any other metabolic disease? *
Has your doctor ever said you have raised cholesterol (above 6.2mmol/L )? *
Has your doctor ever said you have a heart condition and should only do physical activity recommended by them? *
Do you have any muscle, joint or back disorders that could be aggravated by physical exercise? *
Do you have any conditions that will prevent you performing exercises including high impact moves, running, jumping, pressing, lifting and an elevated heart rate? *
Have you ever felt pain in your chest when you do physical exercise? *
Is your doctor currently prescribing you drugs or medication? *
Have you ever suffered unusual shortness of breath at rest or with mild exertion? *
Is there any history of coronary heart disease within your family? *
Do you often feel faint, have spells of severe dizziness or have lost consciousness? *
Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)? *
Do you currently smoke? *
Do you currently exercise on a regular basis (at least 3 times per week) and / or work a job that is physically demanding? *
Are you, or is there any possibility you might be pregnant? *
Do you know any other reason you should not participate in a physical activity programme? *
If you answered YES to one or more questions: If you have not recently done so, consult with your doctor before increasing your physical activity. Seek advice from your Doctor for: I. Unrestricted physical activity starting off easily and progressing gradually, and II. Restricted or supervised activity to meet your specific needs, at least on an initial basis
The Small Print
Payment *
I agree to pay in advance for the session(s) or, for cash payments, at the end of the first session . All packages must be paid in full in advance.
Medical/Liability Waiver *
I declare that the information that I have given is true and correct and I hereby recognise the inherent risks with physical training and assume any such risks. I release Billy Morgan from all liability should anything befall me in the course of these coaching services and recognise that the advice and physical training that he provides is not meant as a substitute for the medical advice of physicians. I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment. I understand the information I have been given to be the truth and consent to the treatment of Anatomy in Motion and will inform Frances of any changes to my medical status if they have changed since completing this online form. I understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected. Frances does not claim to cure or to diagnose any medical condition in the same regard as a physician, as her opinion is that of a holistic, complementary and alternative therapist and her professional opinions, advice, examinations and recommendations do not constitute the medical advice of a doctor/physician.
Assumption of Risk *
I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.
Declaration of Consent *
I have completed the Par-Q form to the best of my ability. By signing this I agree that all the information above is correct as of today's date and that if there are any changes to my health I will notify Movementum and if I am ever in doubt about something I hereby agree to communicate clearly in asking for help.
Privacy Policy *
We do not share any of your information with any third parties or profit from you personal information and data. Our Privacy Policy is at the bottom of each page.
Please write your name or initials in the box below. By signing this form electronically you are agreeing to the terms and conditions herein.
Date Today: *
Date Today:

*ALL SESSIONS, WORKSHOPS AND EVENTS ARE FINAL SALE. REFUNDS NOT PERMITTED.
MISSED APPOINTMENTS WILL RESULT IN THE EARLIEST AVAILABLE RESCHEDULE DATE.*