Mamau Ffit Health Form

Mamau Ffit

Pre & Postnatal Health & Wellbeing.
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Emergency name and contact details *
Are you currently pregnant or suspect you may be? *
Date of postnatal check (with youngest child) DD/MM/YY
Number and age of children (or N/A) *
What type of delivery did you have? *

Vaginal Elective caesarean section Emergency caesarean section N/A
Details of current or previous pregnancies and postnatal recovery
Medical history (please select those which apply)

Pelvic Girdle Pain Pelvic floor Dysfunction (eg, incontinence or urgency to use the toilet) Prolapse C - Section wound discomfort Perennial cut/tear Lower back pain Sciatica pain High/low blood pressure Diabetes Joint pain or movement reduction Unexplained vaginal bleeding Perinatal mental health illness other
If you have ticked any of the above, please give details and let us know if you are STILL suffering with any of the above currently -
Please give details of any other previous medical history you think may be important for your Mamau Ffit instructor to know about to help you on your fitness journey
Exercise frequency *

None at all 1-2 times per week More than 3 time per week
What goals would you like to achieve with Mamau Ffit?
Where did you hear about us?
In order to keep you updated with class information, we may need to contact you 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) *

Text Email Phone
Please tick the box below if you’d like to be added to our mailing list to be kept up to date with all the latest at Mamau Ffit including special offers and priority booking for new programmes. This will NOT be shared with any other business.

I’d like to join the mailing list
Sometimes during classes, photos and videos are taken to be used on Social Media and other marketing channels including the website, please tick here to give consent *

I consent for all I do not consent I consent to pictures of me only I consent to pictures of my child/children only
Please tick here to confirm you have read and understood the Terms and Conditions (available from your instructor) *

I have read the terms and conditions
Whilst we endeavour to ensure the safety of all participants, all exercise comes with some risks, and Mamau Ffit will not be held responsible for any injury or damages incurred. Should your medical or fitness needs change during your time with Mamau Ffit, it is your responsibility to inform your instructor *

I understand and accept the above statement
Data Protection: The information you have provided in this form will be used for my purposes only and will not be shared with any third party without your permission. It will be stored safely on my private computer *

I agree
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