Maternally Fit x Frome Birth Talk
Please complete this form as accurately as possible to enable Maternally Fit to care for you as best we can. If any of your personal information changes, please notify us as soon as possible. Your personal information will remain confidential.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Where did you hear about Maternally Fit?
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Emergency contact name
Relationship to you
Their phone number
Please enter a valid phone number.
Are you..?
Pregnant
Postnatal
Planning a pregnancy
Other
If you are currently pregnant, please complete the below. If not, you can skip!
When is your estimated due date?
-
Month
-
Day
Year
Date
Is this an IVF pregnancy?
Yes
No
Is this a multiples pregnancy?
No
Yes, twins
Yes, triplets
Yes, more!
Where are you planning to give birth?
Name & contact info of your care provider:
During this pregnancy, have you had any of the following?
High or low blood pressure
Vaginal bleeding
Incompetent cervix
Portion of the placenta over cervix
Severe morning sickness
Severe abdominal pain / cramps
Varicose veins
Gastric reflux
Back pain
Pubic bone pain or buttock pain
Neck pain
Knee, shoulder or wrist pain
Swollen hands or feet
Severe fatigue
Continence problems
Other
If you said 'yes' to any of the above, please give details:
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Previous pregnancy history
How many previous pregnancies have you had?
Previous birth information
Type of delivery
Baby weight
Complications
First birth
Second birth
Third birth
Fourth birth
Fifth birth
Have you experienced pregnancy or baby loss?
Yes
No
If yes, please provide details:
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General Health Information
Please indicate if you have a history of the following conditions
Heart problems
Lung problems
Epilepsy
Diabetes
Arthritis
Anaemia
Anxiety / depression
Muscle / joint injuries
Other
If you ticked 'yes' to any of the above, please provide details:
Please give details of any regular medications you take:
Would you consider yourself a regular exerciser? If yes, what have you been doing lately?
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Disclaimer and terms & conditions
1) I agree to inform Maternally Fit* in writing of any change to my pregnancy or health, or of any condition that would affect my ability to participate in a Maternally Fit class, prior to the commencement of a session. 2) It is my responsibility to inform my medical carer that I am participating in Maternally Fit classes. 3) Maternally Fit* will not be held responsible in any way for circumstances / injuries that result directly or indirectly from Maternally Fit classes. 4) I agree to attend Maternally Fit classes weekly (excluding holidays and illness). If I arrive more than 5 minutes late or wish to leave early, I will not be able to participate in the class, and that class will be forfeited. 5) I understand that if I do not advise Maternally Fit* that I am unable to attend a class before 9am for evening classes and by the evening before for morning classes I will forfeit that class. With sufficient notice, my cancelled class will be replaced. 6) I understand that sessions are valid for 12 months from date of purchase, and that it is my responsibility to use all my sessions before they expire. 7) I understand that sessions are not refundable for any reason apart from miscarriage or termination of pregnancy. 8) Maternally Fit* reserves the right to vary venues, times, prices and class format. Notification of any changes will be made by email, phone or in person. 9) Maternally Fit* reserves the right of admission to our classes. 10) I have read all the above statements and agree to all Terms and Conditions. Maternally Fit * includes directors and staff
Yes, I agree
No, I do not agree
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