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 Name Last Name
Email *
example@example.com
Home Number *

Area Code Phone Number
Mobile Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City County

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

Area Code Phone Number
Dr/Midwife: *
Dr's Address *

Street Address

Street Address Line 2

City County

Post Code
Dr's Phone Number *
Due date *

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

Yes No
If yes, please say why....
Are you currently attending any other exercise classes? *

Yes No
If yes please give details...
Have you ever had or do you currently have any injuries? *

Yes No
If yes please give details...
Do you suffer with backache? *

Yes No
Do you have any special needs? *

Yes No
If yes please give details...
Have you, or do you suffer from any of the following? *

Anaemia Epilepsy Diabetes Asthma High Blood Pressure Heart Disease Thrombosis None of the above
Is this a multiple pregnancy? *

Yes No
If yes please give details...?
Have you had assisted conception? *

Yes No
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 *

Yes No
Have any medical professional diagnosed Placenta Previa? *

Yes No
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? *

Yes No
Have you noticed any swelling (oedema)? *

Yes No
Do you have difficulty walking? *

Yes No
Do you have pubic pain or have you ever been told that you have Symphysis Pubis Disfunction? *

Yes No
Have you been admitted to hospital up to this date? *

Yes No
If Yes, to the above question, please give details
What exercise have you been doing recently? *

Walking Running Cycling Swimming Pilates Yoga Circuits HIIT or LIIT Other
Exercise intensity... *

Hard Medium Low Other
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.
Have you had COVID-19? This will have been diagnosed by your health professional. *

Yes No
If Yes, when?
If you said, Yes, to having COVID have you experienced what you consider to be any signs or symptoms of Long-COVID?
If not, have you noticed any changes to your normal level of energy, physical activity or exercise that has been altered or seems to be worsened since your exposure to the virus?
Have you had the COVID-19 vaccine? *

Yes No
If Yes, when?
Have you had one jab or two? Please include dates.
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

Yes No
Your Signature *

Clear
Date

Day Month Year
Date
Please verify that you are human *
Should be Empty:

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