PRE-SCREENING FOR ANTE NATAL & POSTNATAL CLASSES
HOW DID YOU HEAR ABOUT BUGGYFIT?
DOCTOR TEL NO
NO OF OTHER CHILDREN
PREVIOUS EXERCISES (briefly outline)
Please tick if you have experienced any of the following and comment below if past or present.
Shortness of breath
Pelvic Floor Issues (stress incontinence/prolapse)
Separated Abdominal Muscles
High Blood Pressure
Is there anything in your medical history you feel could affect your ability to exercise?
Are you taking any medication? Please give details:
Is there anything about your pregnancy or birth you feel is relevant to the participation in an exercise programme?
What concerns you most about pregnancy, birth or the postnatal period?
What are your goals or reasons for participating in exercise?
Type of Delivery?
Did you have an episiotomy?
Are you breastfeeding?
Are you getting up at night?
How much sleep are you getting?
Are you doing any other exercise? Please give details:
I can confirm that I have had the all clear by my GP to commence suitable postnatal exercise. I am aware that I must feel well prior to each class and will notify you (the trainer) should I feel unwell at any time during the class.
Whist I am aware that every effort has been taken to ensure this exercise class is suitable for postnatal women, I understand that my participation and the safety of both my child/children and myself are my responsibility.
Do Not Fill This Out