Postnatal Exercise Form

Postnatal Exercise Form

Please read the following questions carefully and answer them to the best of your knowledge. Regarding Postnatal - It doesn't matter if you have had a baby 6 weeks ago or 16 years ago, it’s imperative that I ask you the right questions so I can serve you to the highest level. Thank you for your time to answer the questions.
Name*

First NameLast Name
Email*
example@example.com
Home Number*

Area CodePhone Number
Mobile Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Occupation*
Age*
Name of contact in case of accident*
Phone number of contact in case of accident*

Area CodePhone Number
Dr/Midwife:*
Dr's Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Dr's Phone Number*
Format: (000) 000-0000.
Date baby was born*

DayMonthYear
Date
How old is your baby?*
Today's date

DayMonthYear
Date
How are you feeding your baby?*

Breast feedingBottle feedingMixture of both breast & bottleStarting solids
Have you finished bleeding since the birth of your baby?*

YesNo
If No, and still bleeding weeks after giving birth this could make you anemic or suggest there is still parts of the placenta that have not be removed. Please seek medical advice*

Yes, I willNo, I need toOther
Have you had your 6 week postnatal check?*

YesNo
Have you been checked for Diastases Recti - Have your abdominals "closed" back up or can you still feel a gap between your abdominals?

YesNoNot sure
Please tick the type of delivery you had, this is important in relation to your pelvic floor*

VaginalForcepsVentouseCaesarean SectionOther
If you had a C - section how is your scar?
Pelvic Floor. Are you able to control your bladder if you run, jump, or exercise*

YesNo
If No, in what way. Please give details.
Have you had a prolapse?*

YesNoNot Sure
Are you generally fit and healthy?*

YesNo
Are you taking any medication?*

YesNo
If Yes, please list your medication and what it's for. Thank you?
Are you struggling with your back since giving birth?*

YesNo
If Yes, to the above question, please give further details
Early Postnatal. Do you bleed after exercise? - If so you need to go back to your GP*

YesNo
Coccyx Pain. Is your coccyx damaged? This potentially could affect your pelvic floor and continence.*

YesNo
Having a baby is life changing - I'd like to ask, how you are feeling emotionally and your mental health state?*
Are there any other relevant medical conditions that I should know about?

YesNo
If Yes, to the above question, please give details
Please don't feel you have to come along and have a hard workout, if you are coming to the class and just joining in, being with a lovely group of people, getting outdoors with your pram and baby is all you can manage then that's wonderful!

Please just come along and join in at a level that suits you.

You'll be amazed how fabulous it will help you feel.

Wrap up and bring a matt and a drink, PLUS your baby bag and spread the word the more the merrier!
The above health responses given are reflective of my current status. I agree to inform Pilates with Esther and my instructor, if there are any changes in my health status due to injury, illness or otherwise. I will consult with my doctor and not partake in the class until I have been advised by my doctor, that it is safe for me to do so. I acknowledge that there are inherent risks in taking physical exercise and that I know of no medical reason why I should not undertake a Pilates/Fitness exercise programme. I also agree to comply with any verbal instructions from the instructor regarding health and safety whilst doing the class at home or face to face.
I have read the statement above and will comply to the best of my knowledge*

Yes
I give my consent for Pilates with Esther to hold my contact details and health screening data and use them to send me class information/newsletters when appropriate.
I have read the statement above and consent to this*

Yes
I give permission for my image to be used in photos and video recordings that may be used on social media platforms for advertising classes run by Esther Fransham and Pilates with Esther. I won't be doing close ups, just more general shots.
I have read the statement above and give permission for my image to be used

YesNo
Your Signature*
Date

DayMonthYear
Date
Please verify that you are human*
Should be Empty: