Mum to Mum Fitness
From Bump To Beyond
Full Name
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Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
Country
Postcode
Phone Number
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Emergency name and contact details
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Date of Postnatal Check DD/MM/YY (if question not relevant to you, just enter n/a)
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What type of delivery did you have (if question not relevant to you just enter n/a)
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Vaginal
Elective caesarean section
Emergency caesarean section
n/a
Name of children and ages (if no children then just enter n/a)
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Details of pregnancy and postnatal recovery (if question not relevant just enter n/a)
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Medical history (please select those that apply)
Pelvic Girdle Pain (pain in pubic area)
Pelvic Floor Dysfunction (eg, incontinence)
Prolapse
C-Section wound/discomfort
Perennial Tear/cut
Lower back/Hip Pain
Sciatica Pain
High/low blood pressure
Diabetes
Unexplained Vaginal Bleeding
Perinatal Mental Health illness
Has your doctor ever said that you have a heart condition (had a stroke, heart attack or heart surgery) and or that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is you doctor currently prescribing medicine for your blood pressure or heart condition?
Do you know any other reason why you should not do physical activity?
Other
Please provide details of any other injuries or conditions that haven't been listed above
Exercise frequency
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None at all
1-2 times per week
More than 3 times per week
What goals would you like to achieve?
In order to keep you updated with class information we may need to contact from time to time. In accordance with GDPR we require consent to contact you by each method so please check the boxes below to indicate your consent (please select all that apply)
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Text about the class that you attend
Email about the class that you attend
Telephone about the class that you attend
Email about Mum to Mum Fitness news and classes
How did you hear about Mum to Mum Fitness classes?
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Search Engine
Word of mouth
Banner/advert outside
Magazine/newsletter
Social Media
Sometimes photos and videos are taken during sessions to be used on social media and other marketing channels. Please tick here to give consent.
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I consent
I do not consent
Please tick here to confirm you have read and understood the Terms & Conditions and Privacy Statement (can be viewed at www.mumtomumfitness.com or copies to be requested)
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I have read the terms and conditions and privacy statement
Please tick here to confirm that you are not aware of a reason as to why you can't participate in a Mum to Mum Fitness class
*
I confirm I am not aware of a reason as to why I can't participate in a Mum to Mum Fitness class
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