Pre-Exercise Screening Form (Pregnancy)

Pre-Exercise Screening Form (Pregnancy)

All information given will be confidential.
Name*

First NameLast Name
Emergency Details
Emergency Contact*

NameTelephone
GP*

NameSurgery Tel
Midwife*

NameTelephone
Hospital*

NameMaternity Telephone
Pregnancy History
Due Date*

DayMonthYear
1. Is this your first pregnancy? (If yes, please go to question 5)*

YesNo
2. Previous pregnancy date/s & Type of delivery
3. Have you ever suffered a miscarriage?

YesNo
If yes, please give details
4. Have you a history of previous complications during pregnancy?

YesNo
If yes, please give details
5. During this pregnancy, have you experienced any of the following?*

Vaginal bleeding or fluid lossDeep back or pubic painDifficulty walkingPalpitations or unusually slow heart beatSudden swelling in hands, feet or faceUterine contractionsLower abdominal pain or crampingHeadache, dizziness or faintnessUnusual breathlessnessFeeling extremely fatigued or hotNoticeable change in baby's movementsNone of the above
I, the undersigned acknowledge that in normal circumstances exercise should not harm my baby or I in any way. I shall inform my instructor of any medical or pregnancy related changes prior to commencing any class and that The Pilates Corner, Pilates with Emma nor the instructor will not be held liable in any way for any unforseen circumstances or for any circumstances of which I should have been aware, but failed to notify them. I give permission to staff of The Pilates Corner to contact any of the emergency contact numbers set out above should the need arise.

I have read the above statement and agree to be bound by in and to release Pilates with Emma from all claims.
Informed consent and disclaimer
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

Pre-Exercise Screening Form (Pregnancy)

Emergency Details

Pregnancy History

Informed consent and disclaimer