|Client Name||Date of delivery|
|Baby's Name||Type of delivery|
|Client Address||6 week check-up date|
|6 week check-up outcome|
|Postcode ||Post natal bleeding status|
|Client Email||Recently fitted Intra Uterine Device (IUD)|
|Client Phone|| |
|Please give details of your Pregnancy & Post Natal, include any complications, illnesses, reasons to visit your Doctor or any other Health Practitioner including Massage, Acupuncture, Pilates, Physiotherapy, Osteopathy, Chiropractor etc.|
|Do you currently or have you ever suffered any of the following conditions? Please tick if YES.|
Readiness & Lifestyle QUestions
|1. Please detail any relevant/important information relating to previous Pregnancies and Post Birth periods, such as periods of illness or negative outcomes.|
|2. Are you taking any medication? Give details:|
|3. What are your goals or reasons for participating in exercise?|
|4. Can you briefly detail your previous and current exercise abilities/activities?|
|5. Is there anything in your medical history you feel could affect your ability to exercise?|
|6. Are you getting up at night? How much sleep are you getting?|
I can confirm that I have had the all clear by my GP to commence suitable postnatal exercise.
I am aware that I must feel well prior to each class and will notify you (the trainer) should I feel unwell at any time during the class.
Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for postnatal women.
I understand that my participation and the safety of both my child/children and myself are my responsibility.
If you would like to receive my Newsletter, with useful post-natal, nutrition and exercise tips then please click either Yes or No to give your consent.