Pre-Exercise Health Questionnaire
Please be as honest as possible
Which session are you interested in attending?
Kangatraining - Tuesday 10am Freeling (FARM Centre) KangaOnWheel - Thursday 9.30am Hewett
Name*
First Name Last Name
Gender
Female Male
Date of Birth*
Day Month Year
Date
Address*
Street Address
Street Address Line 2
City State
Postcode
Phone Number*
Email*
example@example.com
Emergency Contact Person*
Name Relation to you
Emergency Contact Phone Number*
How did you hear about Kangatraining?
Health Professional Referral Kangatraining Australia Facebook Page Kangatraining LR&AP Facebook Page Google Flyers Word of Mouth from a Friend/Relative

Please specify if you have one of the following pre-existing condition*

	Yes	No
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever feel faint , dizzy or lose balance during physical activity/exercise?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? (If so, you will need a current action management plan before commencing Kangatraining)
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Do you ever experience unexplained pains or discomforts in your chest at rest or during physical activity/exercise?
Are you currently pregnant? (If pregnant, you can only participate in Pre-Kanga)

If you answered 'Yes' to any of these 7 questions, you MUST obtain written medical clearance from an appropriate health professional prior to commencing Kangatraining.
Baby's Name
First Name Last Name
Baby's Date of Birth*
Day Month Year
Date
Baby's current weight*
Type of delivery*
Vaginal Caesarean Assisted
Date of Post Natal Check up*
Day Month Year
Date
Do you have a medical clearance to start exercise from your GP?*
Can you briefly detail your past and current exercise levels*
Are you breastfeeding?*
Are you currently taking any medications? If so please also specify what they are prescribed for.*

Please tick if you have ever experienced any of the following conditions:*

	Yes	No
Symphysis Pubis Dysfunction (pain in the central pubic area)
Sacrum or Sacroiliac Joint Pain (pain in the very lower mid back - top of buttocks)
Bleeding during or after exercising or any unexplained bleeding
Carpal Tunnel Syndrome (Wrist/finger/hand forearm - pain/numbness or tingling)
Knee Pain (Side, front or back)
Upper Back/Neck/Shoulder Pain
Coccyx Damage or Pain
Separation of your abdominal muscles
Incontinence (Urinary or Faecal)
Prolapse (Uterine, Bladder, Rectum, Vaginal)
Breast Health/Breastfeeding Issues/Mastitis within the last 3 months
Piles/Haemorrhoids/Constipation
Episiotomy Cut, Painful Perineum or Tears
Nerve damage sustained from birthing (Pudendal)
Gestational Diabetes
C-section wound discomfort or slow healing or ongoing numbness
Anaemia or taking iron medication
Joint/Muscle Pain
Buttock/Piriformis Pain/Sciatica
Varicose Veins
Other e.g. weak pelvic floor

Type a question

	Yes	No
High Blood Pressure
High cholesterol
High blood sugar levels
You have spent time in hospital (including day admissions) for any medical condition/illness/injury in the past 12 months
Any muscle, bone or joint pain or soreness made worse by particular types of activities

If you have ticked 'yes' to any of the above conditions, it is recommended you seek guidance from an appripriate allied health professional prior to undertaking physical activity/exercise
Does your baby have any health/medical issues relevant to this class?*
Yes No
Hip Dysplasia
Contraindications to being in a sling? e.g. head control or neurological issues.
Other
Do you own a baby carrier? If yes, what type? (Please note some carriers are not appropriate for Kangatraining and you may be asked to use a hire carrier free of charge)*
Have you experienced any problems using a baby carrier? If so, please detail:
Is there any other information you would like your Kangatrainer to be aware of?
Classes are often conducted outdoors (either as Kangatraining or KangaOnWheel). Do you have any experience with the following*
Yes No
Allergies to grass/pollen/pollution
Reaction to insect bites
Heat exhaustion/stroke
Anxiety about exercising in public
If you ticked 'Yes' to any of the above, please list details here. Otherwise do you have any other concerns about training in an outdoor environment?
Kangatraining/ PreKanga/ KangaBurn/ KangaOnWheel/ KangaMix/ KangaTrail Consent and Waiver

I hereby understand and acknowledge that the training, programs and activities provided by Kangatraining may expose me and/or my child to inherent risks including, but not limited to, accidents, injury, illness and death. I assume all risk of injuries associated with the participation including, but not limited to, falls, contact with other participants, use and hire of baby carriers, the effects of weather including heath and/or humidity, and all other such risks being known and appreciated by me.

I acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with my own, or my child’s, participation in the activity. I acknowledge that I am physically fit and mentally capable of performing the physical activity I choose to participate in. I confirm that if I am pregnant I have received written consent from my doctor that I am able to participate in chosen activity. I confirm that where I have hired a baby carrier, that my child does not exceed the manufacturer’s recommended weight of 20kg.

After having read this waiver and knowing these facts, and in consideration of acceptable of my participation and Kangatraining furnishing services to me, I agree, for myself and anyone entitled to act on my behalf to indemnify and to keep indemnified, Kangatraining its servants and licensee, and each of them against all actions, costs, claims, charges, expenses, penalties, demands and damages whatsoever which may be bought or made by me or on my behalf.I undertake to indemnify and hold harmless and free, Kangatraining and its licensees, from any and all claims of whatsoever nature or cause (including negligence) and however arising, which may be made by myself or anyone else on my behalf who suffer any damages (including but not limited to damages arising from or related to personal injury, death and/or loss of support) of whatsoever nature. I agree to comply with all the rules, regulations and instructions in relation to the chosen activity.
I have read and understood the content and important consequences of this document and acknowledge that I am bound thereby.
Clear
Privacy Statement
The personal information contained in this document is to provide contact information and medical details for individuals wishing to undertaking exercise/activity with Kangatraining. This information may be disclosed to medical practitioners or designated third parties should there by an issue or emergency, and in accordance with the Information Privacy Act 2009 (Qld) and The Privacy and Personal Information Protection Act 1998 (NSW) and Privacy Act 1998 (WA) and Information Act 2002 (NT) and Freedom of Information Act 1982 (Vic) and in compliance with the Information privacy principles established by the South Australian Privacy Committee.
By signing this, I give permission for this to occur
Clear
Photographs may be taken during class and used for publicity and promotional purposes. Do you give permission for the use of photographs of yourself and your child for promotional and publicity purposes?*
Yes No
Should be Empty:

	Yes	No
Hip Dysplasia
Contraindications to being in a sling? e.g. head control or neurological issues.
Other

	Yes	No
Allergies to grass/pollen/pollution
Reaction to insect bites
Heat exhaustion/stroke
Anxiety about exercising in public

Pre-Exercise Health Questionnaire

If you answered 'Yes' to any of these 7 questions, you MUST obtain written medical clearance from an appropriate health professional prior to commencing Kangatraining.