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Pre & Post Natal Pilates

Pregnancy Disclaimer Form

Please complete this form before attending any class

Name

First Name

Last Name

Residential Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth

YYYY

Phone number

Name & Tel No. of your doctor

Due Date:

How many weeks pregnant are you?

We welcome women from their 16th week of pregnancy (if you are enrolling for our Pregnancy & Post Natal Private classes it is from the 1st trimester) If you are less than 16 weeks pregnant please consult your GP before attending classes. Please read the following questions carefully and thoroughly. Answer each question honestly to the best of your knowledge by ticking either yes or no. If you answer yes to any of these, please discuss with Rachel. Please indicate if you have experienced any of the following, answering yes/no.

Miscarriage in earlier pregnancy

Any pregnancy complications now or in the past

Any problems with exercise before or during pregnancy

Pre eclampsia

Symphysis pubis dysfunction

Any current acute sickness

Any blood pressure problems

High/Elevated Blood Pressure

Low Blood Pressure

None

Any conditions or past injuries, which may limit the range of movement on any part of your body? If so please describe:

Please list any medication you are currently taking:

You now need to agree to the client disclaimer below before participating in our classes. Please read through and put a tick in the box provided.

I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with the instructor, my Doctor and/or Midwife. I understand that any exercise program has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I understand that I participate in all classes entirely at my own risk, and any loss, damage, injury or any other mishap will not be the responsibility of the class organiser or teacher.

I agree

Pregnancy Disclaimer Form

LET’S GO!