Pregnancy Disclaimer Form

Name *

First

Last

Email *

Contact Number *

Date of Birth and Age (DD/MM/YYYY - XX) *

Name & Tel No. of your doctor *

Due Date *

How many weeks pregnant are you? *

We can only take women during their first trimester. *

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 blood pressure problems *

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 disclaimer below before participating in any of our classes. Please read through and put a tick in the box provided. *

I agree *

Name