Pregnancy Exercise Form

Pregnancy Exercise Form

Please read the following questions carefully and answer them to the best of your knowledge. 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*
Due date*

DayMonthYear
Date
Have you ever been advised, by your Dr or other medical professional, not to exerise?*

YesNo
If yes, please say why....
Are you currently attending any other exercise classes?*

YesNo
If yes please give details...
Have you ever had or do you currently have any injuries?*

YesNo
If yes please give details...
Do you suffer with backache?*

YesNo
Do you have any special needs?*

YesNo
If yes please give details...
Have you, or do you suffer from any of the following?*

AnaemiaEpilepsyDiabetesAsthmaHigh Blood PressureHeart DiseaseThrombosisNone of the above
Is this a multiple pregnancy?*

YesNo
If yes please give details...?
Have you had assisted conception?*

YesNo
If yes, please give details...
Have you had any vaginal bleeding since conception? If yes, then we advise you to consult your midwife of GP*

YesNo
Have any medical professional diagnosed Placenta Previa?*

YesNo
Should you experience any vaginal bleeding or discharge at any time you should stop exercising and consult your doctor or midwife.
Have you had excessive nausea or vomiting?*

YesNo
Have you noticed any swelling (oedema)?*

YesNo
Do you have difficulty walking?*

YesNo
Do you have pubic pain or have you ever been told that you have Symphysis Pubis Disfunction?*

YesNo
Have you been admitted to hospital up to this date?*

YesNo
If Yes, to the above question, please give details
What exercise have you been doing recently?*

WalkingRunningCyclingSwimmingPilatesYogaCircuitsHIIT or LIITOther
Exercise intensity...*

HardMediumLowOther
How long - weeks/years?
How many times a week?
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, and socialising 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.
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*

Clear
Date

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