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Specialized Prenatal Fitness Programs Client Intake Form

I. Client Information

First Name

Last Name

Date of Birth

Street Address

City

State/Province

Postal/Zip Code

Phone Number

Email Address

Emergency Contact Name

Emergency Contact Phone Number

Referring Physician (if applicable)

Physician's Phone Number

II. Pregnancy Information

Current Estimated Due Date (EDD):

Number of Weeks Pregnant:

Number of Previous Pregnancies:

Number of Live Births:

Any complications during previous pregnancies?

If yes, please explain:

Current Pregnancy Complications (if any):

Are you currently under the care of a physician or midwife?

Date of Last Prenatal Appointment:

Have you been cleared for exercise by your physician or midwife?

If yes, are there any specific restrictions or recommendations? (Please provide details):

Are you experiencing any of the following: (Check all that apply)

Vaginal bleeding

Dizziness or fainting

Chest pain

Regular painful contractions

Headache

Calf pain or swelling

Leakage of amniotic fluid

Shortness of breath prior to excercise

Other (please specify):

III. Health and Fitness History

Pre-pregnancy fitness level:

Sedentary

Lightly Active

Moderately Active

Very Active

Current fitness level:

Sedentary

Lightly Active

Moderately Active

Very Active

Regular exercise prior to pregnancy?

If yes, please describe:

Current exercise routine (if any):

Any current or past injuries or medical conditions?

If yes, please specify:

Any allergies?

If yes, please specify:

Are you currently taking any medications?

If yes, please list:

Do you have any allergies?

If yes, please list:

Do you experience any pain or discomfort during physical activity?

If yes, please describe:

Do you have any pelvic floor concerns?

If yes, please specify:

IV. Program Options

Please select the program(s) you are interested in:

 

Individual Programs:

Personalized Prenatal Fitness Training (One-on-one sessions tailored to your needs)

Pelvic Floor Focused Training

Posture and Core Restoration

Preparation for Labour and Delivery Fitness

Group Programs:

Prenatal Yoga

Prenatal Pilates

Prenatal Strength and Conditioning

Prenatal Water Aerobics

Prenatal Education and Fitness Workshops

Online Programs:

Online Prenatal Fitness Classes

Online Pelvic Floor Training

Online Prenatal Education

V. Program Suitability Questions

To ensure the selected program(s) are suitable for you, please answer the following:

 

Which days and times are you generally available for classes or training?

What are your primary fitness goals during pregnancy?

Maintain fitness

Improve strength

Reduce discomfort

Prepare for labor

Other:

Do you have any limitations that may affect your participation in group classes?

Mobility issues

Pain

Discomfort

Other:

Are you comfortable working out in a group setting?

If you selected individual training, what are your specific areas of focus?

If you selected online programs, do you have the necessary equipment and internet access?

What are your comfort levels with online fitness classes? (Scale: 1-Not at all, 5-Very comfortable)

Do you have any concerns about being in a public gym setting?

What is your preferred method of communication?

Email

Phone

Text

Other:

What are your expectations for this prenatal fitness program?

VI. Informed Consent and Liability Waiver

I have accurately completed this intake form.

I understand that physical activity involves risks, and I assume full responsibility for any injuries that may occur.

I have been cleared for exercise by my physician or midwife, and I will immediately inform my instructor of any changes in my health or pregnancy.

I understand that the instructor is not a medical professional and cannot provide medical advice.

I consent to participate in the selected prenatal fitness program(s).

I hereby release and discharge [Your Business Name] and its instructors from any liability related to my participation in these programs.

 

Client Signature:

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Important Considerations:

  • HIPAA/Privacy: If you are in the United States, ensure your form and data handling comply with HIPAA regulations. In other regions, adhere to local privacy laws.
  • Regular Updates: Encourage clients to update their information if there are any changes in their health or pregnancy.
  • Physician Clearance: Always confirm that the client has received physician clearance before starting any exercise program.
  • Individualized Approach: Use the information from the intake form to tailor the program to each client's specific needs and limitations.
  • Professionalism: Maintain a professional and supportive environment for all clients.

Let's break down the detailed insights into each section of the Specialized Prenatal Fitness Programs Client Intake Form:

1. Client Information:

  • Purpose: This section establishes basic contact and identification details.
  • Insights:
    It ensures you can easily contact the client and their emergency contact.
    Knowing the client's date of birth helps verify their identity and may be relevant for certain age-related considerations.
    The address is useful for record-keeping and potential marketing purposes.
    The referring physician's information is crucial for communication and collaboration, especially if the client has specific medical needs.

2. Pregnancy Information:

  • Purpose: This is the most critical section, as it directly relates to the client's pregnancy and potential risks.
  • Insights:
    EDD and Weeks Pregnant: These are fundamental for tailoring the program to the client's current stage of pregnancy. Different trimesters require different exercise modifications.
    Pregnancy History: Previous pregnancy complications can indicate potential risks in the current pregnancy.
    Current Complications: This section is vital for identifying contraindications to exercise. Any "yes" answers require careful consideration and potential physician consultation.
    Physician Clearance: This is non-negotiable. You must have documented proof of physician clearance before allowing a client to participate.
    Symptom Checklist: The list of symptoms is crucial for identifying potential warning signs. If a client experiences any of these, they should be advised to consult their physician immediately.

3. Health and Fitness History:

  • Purpose: This section provides context for the client's fitness level and potential limitations.
  • Insights:
    Pre-pregnancy and Current Fitness Level: This helps you gauge the client's baseline and adjust the program accordingly.
    Exercise History: Understanding their past exercise habits helps you assess their experience and comfort level with different types of activity.
    Injuries and Medical Conditions: This is essential for identifying potential limitations and modifications.
    Medications and Allergies: This is crucial for safety, as some medications and allergies can affect exercise performance.
    Pain and Discomfort: Identifying any pain or discomfort allows you to address it proactively and prevent further injury.
    Pelvic Floor Concerns: This is extremely important, as the pelvic floor is significantly affected during pregnancy. Knowing these issues will allow you to tailor the program to help these issues.

4. Program Options:

  • Purpose: This section allows the client to select the programs that interest them.
  • Insights:
    It provides a clear overview of the services you offer.
    It helps you understand the client's preferences and tailor the program accordingly.
    By listing multiple options, you can reach a wider client base.
    By listing online options, you allow for clients that cannot make it to in person sessions.

5. Program Suitability Questions:

  • Purpose: This section helps you determine if the selected program(s) are appropriate for the client.
  • Insights:
    Availability: This ensures the client can attend classes or training sessions.
    Fitness Goals: This helps you align the program with the client's expectations.
    Limitations and Comfort Levels: This allows you to address any potential barriers to participation.
    Communication Preferences: This ensures you can effectively communicate with the client.
    Expectations: This helps you manage client expectations and ensure satisfaction.

6. Informed Consent and Liability Waiver:

  • Purpose: This section protects you and your business from liability.
  • Insights:
    It ensures the client understands the risks involved in exercise.
    It confirms that the client has provided accurate information.
    It releases you from liability for any injuries that may occur.
    It reinforces the fact that you are not a medical professional.

7. Notes (For Instructor Use):

  • Purpose: This section provides space for you to document any relevant observations or follow-up actions.
  • Insights:
    It allows you to track client progress and identify any potential issues.
    It provides a record of any modifications or adjustments made to the program.
    It helps you maintain consistency and professionalism.

Overall Insights:

  • The intake form is a crucial tool for ensuring client safety and program effectiveness.
  • It should be comprehensive and cover all relevant aspects of the client's health and pregnancy.
  • It should be reviewed and updated regularly to reflect any changes in the client's condition.
  • It should be treated as confidential and handled in accordance with privacy regulations.
  • The form creates a basis for a strong client/trainer relationship.
  • It allows you to provide a much more personalized and safe program.

Mandatory Questions Recommendation

Please remove this mandatory questions recommendation section before publishing.


While all questions are important for a comprehensive understanding, some are absolutely mandatory for safety, legal protection, and the ability to provide appropriate services. Here's a breakdown of the critical mandatory questions on the provided Specialized Prenatal Fitness Programs Client Intake Form:

Without these, you should NOT proceed with training the client:

1. Client Information:

  • Full Name: Essential for identification and record-keeping.
  • Date of Birth: Helps verify identity and can be relevant for age-related considerations.
  • Emergency Contact Name & Phone Number: Crucial in case of any medical emergency during a session.

2. Pregnancy Information:

  • Current Estimated Due Date (EDD) & Number of Weeks Pregnant: Fundamental for understanding the stage of pregnancy and tailoring exercises appropriately.
  • Are you currently under the care of a physician or midwife? (Yes/No): This is a critical indicator of whether they are receiving proper prenatal care.
  • Have you been cleared for exercise by your physician or midwife? (Yes/No): This is non-negotiable. You must have confirmation of medical clearance.
  • If yes, are there any specific restrictions or recommendations? (Please provide details): You need to know any limitations or guidelines provided by their healthcare provider.
  • Are you experiencing any of the following (symptom checklist): These questions screen for potential red flags and contraindications to exercise during pregnancy. Any "yes" answer warrants further discussion and potentially requires physician re-evaluation.

3. Informed Consent and Liability Waiver:

  • Client Signature & Date: This legally signifies that the client understands the risks, has provided accurate information, and agrees to the terms of participation and liability waiver. Without a signature, the waiver is not valid.

Why these are Mandatory:

  • Safety: The pregnancy information and physician clearance are paramount for the safety of both the mother and the baby. Exercising without medical clearance or while experiencing contraindications can have serious consequences.
  • Legal Protection: The informed consent and liability waiver protect your business from potential legal action in case of injury, provided you have acted responsibly and within the scope of practice.
  • Providing Appropriate Services: Knowing the stage of pregnancy, any restrictions, and the client's health history is essential for designing a safe and effective prenatal fitness program tailored to their individual needs.

Important Note:

While the above are strictly mandatory, strongly encourage clients to answer all other questions. The more information you have, the better equipped you are to provide a safe, effective, and personalized experience. If a client is hesitant to answer certain questions, explain why the information is helpful for their well-being and program suitability.

In summary, prioritize the questions related to medical clearance, current pregnancy status, potential warning signs, and the signed liability waiver before commencing any training sessions.


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