Fitness In Mind Registration

Sign up for Fitness In Mind™

To get started, please complete the registration form below. A member of the Fitness In Mind™ team will be in touch to get you ready for your first session. If you need help, give us a call on 01277 246 057.

Section 1: Personal Details

* Required

Title

First Name *

Last Name *

Email Address *

Home Phone Number *

Date of Birth *

Home Address *

City *

State *

Zipcode/Postcode *

Country *

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No

Do you ever feel pain in your chest when you do physical activity?
Yes
No

Have you ever had chest pain when you were not doing physical activity?
Yes
No

Do you ever feel faint or have spells of dizziness when you do physical exercise?
Yes
No

Do you have a joint problem that could be made worse by doing physical activity?
Yes
No

Have you ever been told that you have high blood pressure?
Yes
No

Are you currently taking any medication which the instructors should be made aware of?
Yes
No

If yes, what?

Are you pregnant or have you had a baby in the last six months?
Yes
No

Is there any other reason why you should not participate in physical activity?
Yes
No

If yes, what?

If you answered YES to one or more questions, talk to your doctor by phone or in person before you start becoming more physically active. Tell your doctor about the questionaire and which questions you answered 'yes' to. You may be able to do any activity you want, as long as you begin slowly and build up gradually, or you may need to restrict youractivities to those which are safe for you.

If you answered NO to all questions, you can be reasonably sure that you can start to become more physically active and take part in a suitable physical activity programme. Remember, begin slowly and build up gradually. If your health changes so that subsequently you answer 'yes' to any of the above questions, inform your fitness or health professional immediately.

Please tick below to confirm you have read the above.

Section 2: Baseline Monitoring

How would you describe your current employment status? Tick all that apply.
Unemployed not looking
Unemployed looking
Volunteer part-time
Volunteer full-time
Education part-time
Education full-time
Employment part-time
Employment full-time
Other
Prefer not to say

Do you have a mental health problem?

How would you describe your mental health problem? Tick all that apply.
Anxiety
Depression
Obsessive Compulsive Disorder (OCD)
Post-traumatic Stress Disorder (PTSD)
Stress
Bipolar Disorder
Eating Disorder
Personality Disorder
Schizophrenia
Other

Describe your regular physical activity over the past six months. Regular physical activity means at least 30 minutes of moderate activity each day for 5 or more days each week.
I am not regularly physically active and do not intend to be so in the next 6 months.
I am not regularly physically active but am thinking about starting in the next 6 months.
I do some physical activity but not enough to meet the description of regular physical activity.
I am regularly physically active but only began in the last 6 months.
I am regularly physically active and have been so for longer than 6 months.

Below are some statements about feelings and thoughts. For each statement, please tick the box that best describes your experience of each over the past 2 weeks.

I've been feeling optimistic about the future

I've been feeling useful

I've been feeling relaxed

I've been dealing with problems well

I've been thinking clearly

I've been feeling closer to other people

I've been able to make up my own mind about things

In the past week, on how many days did you do at least 30 minutes of moderate activity that made you breathe a little harder than normal?

In the past week, on how many days did you do LIGHT activities that didn't make you breathe harder than normal?

On average, how much time did you spend doing LIGHT activities on one of those days?

In the past week, on how many days did you do MODERATE activities that made you breathe a little harder than normal? E.g dancing.

On average, how much time did you spend doing MODERATE activities on one of those days?

In the past week, on how many days did you do VIGOROUS activities that made you breathe much harder than normal? Eg. fast running.

On average, how much time did you spend doing VIGOROUS activities on one of those days?

To what extent does each statement describe your current relationships with other people?

There are people I can depend on to help me if I really need help

There are people who enjoy the same social activities I do

I feel part of a group of people who share my attitudes and beliefs

I have a close relationship that provides me with a sense of emotional security and wellbeing

There is someone I could talk to about important descisions in my life

I have relationships where my competence and skills are recognised

There is a trustworthy person I could turn to for advice if I were having problems

I feel a strong emotional bond with at least one other person

There are people who admire my talents and abilities

There are people I can count on in an emergency

Section 3: Equality Monitoring

What is your age?

What is your gender?

What is your ethnicity?

Are your day to day activities limited because of a health problem or disability?

How would you describe your health problem or disability?

What is your sexual orientation?

Where did you hear about the Fitness In Mind programme?

Section 4: Consent

DATA SHARING

I agree to the programme sharing information about me with other selected organisations in order to support me. I understand that I will be consulted on each referral by a member of the team, and that I can choose to withdraw from the programme at any time.

TALENT RELEASE

I agree to the programme using my name, quotations and images of me for the purpose of marketing. I understand that I will be consulted on each campaign by a member of the team, and that I can choose to withdraw from the programme at any time.

DATA PROTECTION ACT 1998

I understand that data will be collected for funding and research purposes, and that I can choose to withdraw from the programme at any time. I understand that all the information provided will be treated in the strictest confidence and securely stored, in compliance with the Data Protection Act.

Signed Name

Guardian Signed Name (If applicable)