POSTNATAL CLASS ENROLLMENT FORM

Personal Information: Name ________________________________________________ Age ________ Address __________________________________________________________ Telephone Number ___________________ E-mail ________________________ Emergency contact:_________________________________________________ Date of giving birth _________________________ Postpartum of _____ weeks.

Caesarian section

Natural birth

1.Are you breastfeeding?

Yes

No

2. Is this your first baby? ____ If not, how many children do you have? ________ 3. Have you had your six week postnatal check-up? Yes No

4. Did you get the approval of your doctor or midwife prior to beginning this fitness program? Yes No 4. Did you have any diastasis recti (separation of the abdominal muscles/ Caesarian section)? _____ How is the separation now? _____________________ 5. Did you experience any back, pelvic or pubic symphasis pain during your pregnancy? If so, did you have treatment? _________________________________________________________________ _________________________________________________________________ 6. Are you currently experiencing any pain in your body? If so, please specify

_________________________________________________________________

7. Did you have high blood pressure ( Pre-Eclampsia) during pregnancy or before? ______ If yes, is it under control now ____________________________ 8. Do you have any other medical conditions we should be aware of ? ________________________________________________________________ 10. General health condition. Please tick: Headaches/Dizziness: Yes Haemorhoids: Yes Back Ache: Yes Varicose Veins: Yes Heart Disease: Yes Thyroid Disease: Yes Epilepsy: Yes Diabetes: Yes Anemia: Yes No No No Yes Yes No No No No No No No No

Asthma / respiratory problems: Difficulty maintaining continence:

Please note: Please be aware that ligaments remain soft from 4-6 months post natally and longer if you are breastfeeding so it is important not to over stretch. Feel free to rest at any time and miss out postures/exercises that do not feel appropriate. Agreement: I understand that whilst every possible care will be taken throughout the class I am responsible for adjusting my practice according to my limitations to ensure that no personal injury occurs. I hereby declare that I take full responsibility for myself during the classes.

We can give you the optimum level of guidance during your post-natal exercise sessions. We need to know of any changes that occur to your health. Sometimes we will advise you to take a break from the sessions or consult your doctor or health professional. In many cases we will ask you to modify your exercises. Therefore it is important to advise your Fitness Trainer about any physical problems before each session so they can modify it appropriately to ensure the exercises are safe for you. I recognize that Fitness Trainer is not able to provide me with advice regard to my medical conditions and that the information in this fitness registration form are used as a guideline to the limitation of my ability to exercise. I understand that I participate in physical activity with advice and medical clearance from my doctor prior to starting.

Signature:_____________________

Date:_________________