Pregnancy Pre-Activity Health Questionnaire

Assumption of Risk and Informed Consent

Exercise programmes are designed to improve muscle tone, strength, endurance and flexibility and may include physical activities such as stretching, using weights and equipment/machines.

When participating in activity/exercise you are likely to experience different levels of intensity over varying lengths of time. As a result you may experience quicker breathing patterns and become hot, as well as feelings of awkwardness depending on your experience or level of fitness.

Each part of the activity/exercise you participate in will be fully explained, you are strongly advised to ask questions if you are not clear about anything.

I confirm 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, stretching, and release or massage work using a foam roller, instrument assisted massage, or massage therapy. I realise that my participation in these activities involves the risk of injury and even the possibility of death. I understand that I am fully responsible for the welfare of my baby at all times and will not participate in any activity that I feel is not safe with my baby. If at any time I feel any pain or discomfort, I will stop performing the activity and notify the instructor. Likewise, if I feel that I should not do a particular exercise for any reason I understand that I must inform the instructor.

I agree to seek medical advice and treatment for any conditions indicated on this form (any question I have answered Yes to), such as pelvic organ prolapse, incontinence, pelvis and back pain, as Vanessa Barker cannot treat these. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, and my instructor will need to be informed of any changes in my condition. It is further expressly agreed that all strength training, cardiovascular exercise, or any other exercise shall be undertaken by me at my sole risk and that Vanessa Barker shall not be liable to me for claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located.

Any information provided by Vanessa Barker is not intended to be a substitute for professional medical advice from a doctor, nutritionist or dietician. You must not rely on this information as an alternative to medical advice, and Vanessa Barker expressly disclaims all responsibility and liability for any damages, loss or injury suffered by you or any third party as a result of this information.

Training includes general nutrition advice, and as with all dietary programmes, you must get your physician’s approval prior to making any changes to your diet, for diagnosis and treatment of illnesses, and for advice regarding medications. Nothing provided is intended as medical advice and is not intended to replace the advice or attention of health‐care professionals. Always consult your physician before beginning or making any changes in your diet and/or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications.

Once you submit this data it is kept on a secure website until I download it, at which point I delete the online copy.

I will keep a password encrypted PDF copy on my laptop (password protected and protected by McAfee LiveSafe) and on a password encrypted KnowHow Cloud Storage as back up.

This information is for me to ascertain whether training/massage is suitable, if so what adaptations I may need to take into account, and whether I need to refer you to a Health Care Provider such as your GP or a Physio. The only circumstances under which I will share any information is if you do indeed see another professional, and give me permission to send them details about why I have referred you, including what training I hope to do with you, so as to get their advice on how to proceed.

I will have a hard copy of some information to bring to our sessions. Session notes have your name, DOB, address and phone number at top. These are kept in a locked filing cabinet.

I will keep this information, as well as records of any sessions we have, until 7 years after you cease training with me, as this is the length of time my insurance requires I retain them, in keeping with The Statute of Limitation in the UK. At the end of this period, or if you have completed this questionnaire but do not subsequently train with me I will delete all data, and use McAfee to shred deleted files. I will shred the hard copies of session notes.

If you would like a copy of the PDF I have please let me know and I will send you all the information I have.

With regards to communication, I am not currently using an email encryption programme. Any emails we send to each other may be vulnerable to viruses or human error. If you send me an email, this can be seen on my personal phone which is password protected. Most emails and text messages will be deleted once they have been read/actioned. However it may be necessary for me to keep some messages if they are relevant to our training.

48 hours notice of cancellation is required for all personal training appointments. Any less will incur full payment of the session fee, although this is at the trainer's discretion: if I can fill the slot for example I will waive the charge. If for any reason I have to cancel you get a full refund.

If you are late the session will not be extended. If the trainer is late additional time will be added to the session or later sessions.

Payment must be made in advance, and any block payments must be redeemed within 6 months. Refunds are at the trainer's discretion.