Healthy Back. Client Enrolment Form All information provided will be treated in the strictest of confidence. Your Contact Details
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1 Name Healthy Back Client Enrolment Form All information provided will be treated in the strictest of confidence Your Contact Details Address Home Telephone Number Work Telephone Number Mobile Number Person to contact in case of emergency Contact number Gender Date of Birth Occupation Some Information About You Current Recreational Activities Previous Recreational Activities How did you hear about the Back4Good Healthy Back classes? Have you been referred by your GP or by any other medical practitioner? If yes, please provide any relevant information here and give their contact details in the box below: Do you give me permission to contact your GP about issues directly relating to your participation in the Back4Good Healthy Back class? GP Name Surgery Address Contact Details Of Your GP
2 General Medical Information Do you suffer from any of the following? If yes, please give details where requested: Diabetes? If yes, please indicate whether IDDM or NIDDM (diet or medication controlled). Are your glucose levels normalised? High or low blood pressure? If high, is it stabilised with medication and do you have medical clearance to exercise? High/Low/Normal Cardiac/heart problems or angina? If yes, do you have medical clearance to exercise? Do you suffer from any vascular conditions or diseases (DVT, aneurysm etc.)? If yes, do you have medical clearance to exercise? Epilepsy? If yes, have your seizures been stabilised with medication? Asthma or other breathing problems? If yes, do you require medication during exercise? Do you suffer from digestive complaints (ulcers, reflux, colitis etc.)? Have you noticed any bowel or bladder dysfunction? Have you noticed any recent unexplained weight loss?
3 Have you ever been diagnosed with any form of cancer? Do you suffer from any neurological conditions or diseases? Pregnancy Are you or could you be pregnant at the moment? Have you had any previous pregnancies? Delivery Types (please tick where appropriate) Natural Caesarean Assisted Forceps Episiotomy Background Information Do you suffer from any inflammatory conditions or diseases (such as rheumatoid arthritis, polymyalgia rheumatica etc.)? Do you suffer from osteoporosis or osteopenia? If yes, please give details, including your T-score if you know it: Have you ever been involved in a major accident (including motor vehicle accidents)? Have you had any surgery? Have you suffered any broken or fractured bones (including stress fractures)? Have you had or do you have any joint or soft tissue problems/injuries (muscle, tendon or ligament)? Have you been diagnosed as hypermobile (excessive joint mobility)?
4 About Your Back If you have, or have had, any lower back pain please provide details here, including the approximate date(s) of your first and any subsequent episodes: Have you ever had any formal diagnosis related to any incidences of lower back pain? If yes, please give details here: What are your goals and expectations on starting your Healthy Back sessions?
5 Additional Information Is there any other information not asked for above that you feel may be relevant to you attending Back4Good Healthy Back classes? Important Information Please advise your Back4Good Practitioner before commencing any session if, for any reason, your health or your ability to exercise changes. It is inadvisable to do any exercise between weeks 8 to 14 of pregnancy, unless by special arrangement with your Practitioner. It is also wise to wait six weeks after the birth before resuming exercise. Back4Good exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting sessions. These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. Your Back4Good Practitioner can accept no liability for personal injury related to participation in a session if: your doctor has, on health grounds, advised you against such exercise. you fail to observe instructions on safety or technique. such injury is caused by the negligence of another participant in the class/studio. Exercise should be performed at a pace which feels comfortable for you. Pain is the body s warning system and should not be ignored. Please inform your Back4Good Practitioner immediately if you feel any discomfort during a session. Please also inform the teacher if you felt any discomfort after a previous session. I understand that Back4Good exercises involve hands-on correction and I hereby consent for my practitioners to work in this way. I confirm that I have read and understood the above advice and that the information I have given is correct. Client Signature Practitioner Signature Date Date
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