Congratulations on taking the first step to your new post-natal life. We are honoured that you have chosen Jump Start to help you with this journey, as we have thoroughly enjoyed helping local Mums get back into shape since 1997!

Please complete the following form and press submit. Your information will then come back to us so that we can get a great understanding of all your pre and post-natal health and fitness history and the goals you are wanting to achieve with Jump Start.

Please Note: We promise to never sell, rent, trade, or share your e-mail with any other organisation.

Post-Natal Health and Fitness Appraisal

PERSONAL DETAILS

First Name: Last Name: Age: D.O.B:

Address: P’Code:

H Phone: W Phone: M Phone:

Email:

Occupation: Employer:

Emergency Contact Person: Ph: Relationship:

What age are your children?

Name: Age: Kindy/School:

Doctor’s Name: Ph:

Medical Practice Name: Medical Practice Suburb:

Do not send a courtesy letter to my doctor advising of my new exercise initiative with Jump Start Personal Training.

Private Health Fund:

Other Health Providers:

Obstetrician/Gynaecologist:	Ph:
Physiotherapist:	Ph:
Chiropractor:	Ph:
Osteopath:	Ph:
Other Health/Medical Provider:	Ph:

CARDIO-PULMONARY SYSTEM

1.Do you have, or have you had, or do you take medications for?	2. Have you ever been told that you have heart problems? Eg
no / or none of the below	no / or none of the below
heart disease (please specify)	heart murmur valve defect
Osteopath:	racing heart irregular beats
high blood pressure	angina
high cholesterol	other

lung disorder (eg asthma, emphysema):	4. Do you have, or have you experienced?
	no / or none of the below
other cardiac problem (include pacemaker)	epilepsy fainting seizures
	dizzy spells convulsions
3. Do you have a family history of?
no or none of the below	5. Have you ever smoked cigarettes?
heart disease high blood pressure	Yes, still do approx a day
high cholesterol diabetes stroke	Yes, but stopped months / years ago.
	Never

MUSCULO-SKELETAL

1. Have you ever experienced any muscular pain or injury in the last 6 months?	3. Have you broken any bones in the last 12 months?
Yes No	Yes No
If yes, please explain:	If yes, please explain:


2. Have you experienced any joint pain or injury in the last 6months?	4. Do you, or a blood relative, suffer from a musculo-skelatal problem, such as osteoporosis or arthritis?
Yes No	Yes No
If yes, please explain:	If yes, please explain:

GENERAL HEALTH

1. Do you have any neurological disorder which may require special needs whilst exercising? Eg Parkinson’s, Alzheimer’s, Multiple Sclerosis, Dementia, Cerebral Palsy.	2. Do you have any allergies which may affect your capacity / ability to exercise?
Yes No	Yes No
If yes, please explain:	If yes, please explain:


3. Are you aware of any medical reason / condition which might prevent you from participating in an exercise program?	4. Are you pregnant now?
Yes No	Yes wks No
If yes, please explain:
	5. How long ago did you give birth? wks mths Natural C-section

	6. Are you breastfeeding? Yes No

NUTRITION

My diet is excellent. I eat lots of fruit and vegetables, and never eat junk food or takeaway food.

Throughout the week, I am pretty good, but on weekends I treat myself.

I eat out all the time, and order takeaway foods whenever I am at home.

Besides hunger, what other reason(s) cause you to eat?

Boredom Social Stress Other

Tiredness Unhappy Nervous

How many glasses of water do you consume during the day?

List 3 areas of your nutrition you would like to improve:	1.
	2.
	3.

ALCOHOL CONSUMPTION

I drink glasses of wine/beer/spirits every night.

I drink glasses of wine/beer/spirits nights a week.

PHYSICAL CONDITION

What priority do you give to health and wellness in your life? (please choose one)

Low Priority Medium Priority High Priority

How would you describe your current condition?

I participate in fun runs. My best time for 10km’s, in the last 12months is mins.

I go to the gym / use a Personal Trainer / run times a week.

I participate in a yoga / pilates class times a week.

I swim times a week.

I play a team sport times a week. That sport is .

I walk times a week for mins each time.

I have not exercised in the last 12months.

I have never exercised.

SLEEP and ENERGY LEVELS

I get approx. hrs sleep every night, and have lots / average amounts / not enough (please circle) of energy throughout the day.

STRESS

On a scale of 1 – 10, how would you rate your stress level? (1 = no stress; 10 = very high stress levels)

List your three greatest sources of stress:	1.
	2.
	3.

Post-natal Goal Planner

What would you like to achieve?		Can you prioritise these goals?
Lose post-natal body fat	Rehabilitation	1.
Develop Exercise Habit	Increase Self Esteem
Tone and Definition	Improve Fitness Level	2.
Reduce Stress	Improve General Health
Increase Flexibility	Muscle Gain (bulk)	3.
Improve Strength	Sport Training
Avoid Post-natal Back Pain	Pre-conception Health	4.
Reduce Blood Pressure	and Fitness (another baby!)
Improve Core Strength	Other	5.

How will you know you have achieved your goals?

When would you like to achieve these goals by?

For how long have you been thinking about getting started?

How many times are week are you prepared to commit to these goals?

What has stopped you before?

With JUMP START - /wk

By myself - /wk

Services What type of services do you believe will help you achieve the results you are after?

Personal Training	'Run 4 Fun' Club
Buddy Training	'Walk 2 Trot' Club
Small Groups	'Fit 2 Box'
Mums With Bubs	Core Strength

What days and times are best for you to exercise?

Mon Tues Wed Thurs Fri Sat

Early Morning

Mid-morning

Late Afternoon

Evenings

Marketing

How did you hear about Jump Start?

Referral from
(our clients receive a special gift when they refer someone!)

I am a returning client

Shop Front

Pamphlet

Local Paper eg Mosman Daily, Northshore Times

Yellow pages

Sydney’s’ Child

Car

Website -> What did you google?

Other

Thank you Gifts

Most of our clients come to us because someone they know has been very happy with the way we have looked after them, and also because of the great results that they have achieved. When we receive these referrals we like to say thank you properly with a gift you would actually enjoy. In the next 2yrs we hope that we do not have to spend any money on advertising & marketing, because all our new ‘jump start family’ will be referred to us by our current happy ‘jump start family’. We hope you can hep us with this goal by encouraging your friends & family to get started with us so they can enjoy the benefits of a healthier life. So if you were to receive a gift for referring someone to us, what would be 3-5 of the most ideal options from the list below.

Book Voucher	A Beauty Therapy Appointment -> My favourite treatment is
Movie Voucher	Hair Appointment -> My favourite salon is
Personal Training voucher	A Hair Appointment -> My favourite salon is
Jump Start Merchandise	Magazine Subscription -> My favourite is
A Massage	Perfume/Aftershave -> My favourite is
Gift voucher to try other Jump Start services	A Restaurant Outing -> My favourite restaurant style is
Food Hamper	A Sporting Event -> My favourite is
Flowers -> My favourite is	A bottle of wine -> My favourite is

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I have read and agree to your terms and conditions.