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.
Format: (00000) 000-000.
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
Submit
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