Date of Birth:
Date of Birth:
Do you require a home visit? *
Travel costs are applicable
Which package would you like? *
For cash payments or bank transfers only. If you've bought via the website you've already chosen before paying (please tick Not Applicable).
Contact preference to book the first session *
If you prefer me to call you to book in please let me know the best times to reach you - saves us playing telephone tennis!
Payment Method: *
Payment in full is required before the first session.
Describe the reason for your visit (e.g if it's for a specific injury, chronic pain etc).
Note your expectations and goals if you having, e.g to climb the stairs without being in pain or the ability to drive pain-free
Do you have or have you ever had: *
Are you currently taking any medication? *
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
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!
Note down if it's for a particular goal or skill, maybe you've got a competition you're training for
(e.g. pull-ups, levers, acrobatics, vaults)
(e.g. cycling, walking to work, gym, classes)
Please be as specific as possible with your average weekly food and drink intake. If you already follow a nutrition plan please email it to me.
On average I sleep well and more than 7 hours a night:
I bruise easily:
When training I often push past pain:
Day-to-day I feel stressed:
My job is stressful:
Day-to-day I have a lot of energy:
Day-to-day I spend more than 4 hours outdoors:
My work shoes are uncomfortable:
I have a sedentary lifestyle:
Are you satisfied with your life?
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? *
Have you had root canal treatment? *
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
How did you hear of Movementum?
Are you comfortable for any photos / videos of yourself to be shared online or on social media? *
I will never post anything without first asking your permission.
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.
Medical Waiver *
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.
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 Movementum 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.
Late Arrival Policy *
I request that you arrive 10 minutes prior to your first session to allow time to fill out any required paperwork and 5 minutes prior to all other sessions. I understand that issues can arise that may cause you to be late for your training sessions. However, I ask that you contact me if this ever occurs so I can do my best to accommodate you.
Cancellation Policy *
I respectfully ask that you provide me with a 24 hour notice of any schedule changes or cancellation requests. When you cancel or miss your appointment without providing a 24 hour notice I am unable to fill that appointment time. For this reason, you will be charged 50% of the service fee for the first missed session and 100% of the service fee for each session after that. I understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhoea within 24 hours prior to your appointment time, I request that you cancel your session. I will do my best to give advanced notice if I need to cancel due to bad weather and ask you do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session charges, but this is determined on a case-by-case basis.
Privacy Policy *
We do not share any of your information with any third parties or profit from your personal information and data. Our Privacy Policy can be found at the bottom of each page.
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.
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:
Package Form.jpg

Package form

Thank you for doing the following:

• Completing this form at least TWO DAYS in advance of the date of your session to allow time to prepare.

• Use the Universal Pain Assessment tool to measure your current pain level.

• Allowing an extra 30 mins for your first private coaching session so the Movement Screen can be completed. (If you’ve booked only one session this doesn’t apply).

• Arriving a little bit early before the sessions to allow us to have a chat, check-in and catch up. If you arrive late, I’m unable to finish late.