top of page

Health Pre Screen Form

Before attending a class in person, or your first Personal Training Session - Please fill out the form below to give us the best information to help you. 

Birthday
Day
Month
Year
Current or Past Health Issues
Are you currently pregnant?
No
Yes
Have you had children?
Yes
No
Do you have any of the follow Pelvic Floor Symptoms
Have you been seen by a Womens Health (Pelvic Health) Physiotherapist * A womens health Physio will be able to check your pelvic strength if you suffer from any form of leaking or pain, or issues in the pelvic floor area.
Yes
No
Have you had any surgeries in your life time?
Yes
No
What is your current level of fitness ?
Sleep Snapshot
Fluid or Beverage Choices
Why do you drink above beverages?
Do you smoke or vape?
Yes
No
What causes the most stress?
What do you want to achieve?
How did you find our about Bootiful Fitness NZ?
bottom of page