New Client Registration - Ante natal

Ante-natal registration and health questionaire

Please complete this form before attending your first ante-natal pilates class

Personal details:

First name

Last name

Address

Date of birth

Day

Month

Year

Phone

Email

GP name and surgery

Next of kin name and phone number

Eparmed x pregnancy:

In the past, have you experienced miscarriage or other pregnancy complications?

Yes

No

If yes please give further detail

Number of previous pregnancies?

Due date

Day

Month

Year

Did you conceive via IVF treatment?

Yes

No

Are you pregnant with twins/triplets?

Yes

No

Have you been advised by a doctor or midwife that there are any risks to you exercising?

Is there anything in your medical history that your feel could affect your ability to exercise?

Are you taking any medications that may affect your ability to exercise?

Did you have any problems during your previous pregnancies, births or in the postnatal period that may impact your ability to exercise?

Consent and terms & conditions:

It is important that you keep the class instructor up to date with any changes to your health or pregnancy during your attendance at pilates classes and you must stop exercising and notify the instructor immediately if you experience any of the following: bleeding, abdominal cramping, contractions, dizzyness, headache, shortness of breath, chest pain or palpitations.

I understand

Your personal and health information will be stored securely in line with GDPR. Please see the privacy policy on this website for more information. Class reminders and booking confirmations will be sent out by email, you can opt out of this at any time by contacting us.

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No refunds will be given for cancellations with less than 24hours notice. You may reschedule to an alternative date up to 24hours before your class.

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