Post Natal Medical and lifestyle questionnaire

PRE-SCREENING

Name

Telephone Number

Email

Please state location of preferred  class?i.e. West Norwood / Beckenham etc

Date of Delivery / Due date

Type of delivery  (Assisted, Vaginal, C-Section):

Breastfeeding Status

which service /class I am interested in

Address

DOB

Emergency Contact

Emergency contact number

6-8 Week Check-Up Outcome

Post Natal Bleeding Status

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

Medical history

Do you current or have you ever suffered any of the following conditions?  Please circle if YES

If you have answered yes to any of the above questions, please give further details

Is there anything else in your medical history that could affect your capacity to exercise?

Are you on any medication? If so please give details

I confirm that I understand that participation in this group is entirely at my own risk and that should I have my baby with me in any of the classes I take full responsibility for my own child.

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