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Online Nutrition and Fitness Coach
Personal Trainer Central Coast
30-Day Vertical Jump Program
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About Me
Services
Online Nutrition and Fitness Coach
Personal Trainer Central Coast
30-Day Vertical Jump Program
Store
My account
Cart
Checkout
Location
Contact
Exercise Readiness for Children & Adolescents
Exercise Readiness for Children & Adolescents
Email
*
Consultation Date
*
Child's Full Name
*
Date of Birth
*
Gender
*
Female
Male
Prefer not to say
Other
Other
Name of Parent/Guardian
*
Address
*
Mobile Phone
*
Has a GP or AHP referred your child?
*
Yes
No
Please provide their contact details
*
Emergency Contact Name
*
Emergency Contact Number
*
Do any of the following medical or physical conditions apply to your child? Tick all that may apply
Asthma
High Blood Pressure
High Cholesterol
Eating Disorder
Unexplained coughing after exercise
A heart condition
Type I Diabetes
Epilepsy
Breathing problems
Cystic Fibrosis
Type II Diabetes
Seizure or convulsion
Is your child currently taking any medications?
*
Yes
No
Please provide medication details
*
In the last 6 months has your child had any of the following (tick all that apply)
Joint or bone pain
Injured or broken bones
Muscular pain while exercising
Does your child have any chronic disability or illness?
*
Yes
No
Please provide details
*
Does your child have difficulty/problems with one or more of the following
Vision
Speech
Balance
Motor Skills
Hearing
Sleep
Is your child allergic to any foods, medications, pollens or allergens?
*
Yes
No
Please provide details
*
Does your child follow a special diet?
*
Yes
No
Has your child ever been diagnosed with a nutritional deficiency?
*
Yes
No
Has your child has surgery in the last 12 months?
*
Yes
No
Informed Consent
*
I give permission for my child to commence the exercise program.
I hereby acknowledge that the information provided above regarding my child's health is to the best of my knowledge, correct. I will inform the trainer immediately if there are any changes to the information provided above.
If you are human, leave this field blank.
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