Name:
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Email Address:
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Telephone number:
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Address:
Date of Birth:
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Height:
Weight:
Emergency Contact Name:
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Emergency Contact Number:
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Relationship to You:
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Name and address of GP:
What time of day and date(s) suit you best?
Do you require a home visit?
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Travel costs are applicable
Which package would you like?
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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
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Payment Method:
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Payment in full is required before the first session.
Do you have or have you ever had:
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If you selected any of the above, please give details:
Are you currently taking any medication?
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Has anything significant happened / or is happening in the past year?
How do you rate your pain today?
Please refer to the Universal Pain Assessment Tool
Are you predominantly a mouth breather?
What kind of training facilities/equipment do you have available?
If you currently take any minerals / vitamins / supplements please list them below:
On average I sleep well and more than 7 hours a night:
I bruise easily:
When training I often push past pain:
I am prone to over-training when I exercise:
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
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?
Anything else I should know?
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?
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Do you have high blood pressure?
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Do you have low blood pressure?
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Do you have Diabetes Mellitus or any other metabolic disease?
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Has your doctor ever said you have raised cholesterol (above 6.2mmol/L )?
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Has your doctor ever said you have a heart condition and should only do physical activity recommended by them?
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Do you have any muscle, joint or back disorders that could be aggravated by physical exercise?
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Do you have any conditions that will prevent you performing exercises including high impact moves, running, jumping, pressing, lifting and an elevated heart rate?
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Have you ever felt pain in your chest when you do physical exercise?
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Is your doctor currently prescribing you drugs or medication?
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Have you ever suffered unusual shortness of breath at rest or with mild exertion?
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Is there any history of coronary heart disease within your family?
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Do you often feel faint, have spells of severe dizziness or have lost consciousness?
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Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?
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Do you currently smoke?
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Do you currently exercise on a regular basis (at least 3 times per week) and / or work a job that is physically demanding?
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Have you had root canal treatment?
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Are you, or is there any possibility you might be pregnant?
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Do you know any other reason you should not participate in a physical activity programme?
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How did you hear of Movementum?
Are you comfortable for any photos / videos of yourself to be shared online or on social media?
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I will never post anything without first asking your permission.
Assumption of Risk
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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
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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
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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.
Session Booking
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If a date cannot be agreed at the end of an in-person session it is up to you, the client, to ensure you book all of your sessions. Movementum will not be held responsible for ensuring all packages and sessions are used and are unable to remind you to book appointments outside of session hours.
Late Arrival Policy
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We 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. We understand that issues can arise that may cause you to be late for your sessions. However, we ask that you contact us if this ever occurs so we can do our best to accommodate you. As we run on a tight schedule, clients who arrive late to their appointment may receive a shorter treatment in the effort not to inconvenience other booked clients.
Cancellation Policy and Missed Appointments
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We want to make our policy as clear as possible as it can be upsetting when people miss or need to change an appointment, often because of genuine and stressful reasons. It is our policy that clients are responsible for all appointments that they have scheduled. Clients who choose not to attend, or those who call to cancel their appointments at the last minute are still responsible for these appointment times.
Therefore the following policy will apply:
We require a minimum of 24 hours’ notice for cancellation of a session via email, phone call or text message.
For missed appointments, or any appointment changed, altered, moved or cancelled for any reason with less than 24 hours’ notice you will incur the full appointment fee. Short notice cancellations (less than 24 hours) will be counted as one of your sessions.
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.
Privacy Policy
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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
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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.
Date Today:
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