Buggyfit Pre-Screening Form Pre-screening form for Buggyfit and postnatal exercise classes. Name* First Name Last Name Your D.O.B* DD MM YYYY Baby's Name First Last Baby's D.O.B/Due Date DD MM YYYY Your occupation*Address* Street Address Address Line 2 City Postcode Mobile Number*Email* Partner's Name & Telephone*In case of emergencyDoctor's Name & Practice*Health conditionsPlease tick if you have experienced any of the following during or after pregnancy: SPD (pelvic girdle pain) Pelvic floor weakness Sacroiliac pain Chest pains Heart disease Diabetes High blood pressure Low blood pressure Multiple births Knee pain/problems Back pain/problems Vaginal bleeding Dizziness/fainting Neck pain/problems Miscarriage Divarification/split abs Constipation Pain in the pelvic floor Posterior pelvic floor weakness If yes please write more information belowIs there anything in your medical history I would need to know?*e.g. hypermobility, back operation, prolapse, cancer, major surgery, IVF?Are you taking any medication?*If so please give detailsIs there anything about your pregnancy or birth you feel is relevant to your participating in an exercise programme? What are your goals or what do you want to get out of a Buggyfit class?*Antenatal Clients OnlyWhat trimester are you in/how many weeks pregnant are you?Were you exercising before you got pregnant and if so what were you doing and how often?Postnatal Clients OnlyDid you have an episiotomy/tears/ventouse?YesNoAre you breastfeeding?YesNoType of deliveryHow much sleep are you getting?What is your diet like?What liquids are you drinking and how much?Are you doing other exercise and did you exercise in pregnancy - if so what and for how long?I can confirm that I have had the all clear/6 week check with my GP to commence suitable postnatal exercise.* I Agree I am aware I must feel well prior to each class and will notify you (the trainer) should I feel unwell during the class.* I Agree Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for ante and post natal Women, i understand that my participation and the safety of both my child/children and myself are my responsibility* I Agree Data Protection: The information you provided in this form will be used for Buggyfit purposes only, by your instructor and will not be shared with any third party without your prior permission. It will be stored for 5 years on your trainer's private computer. Please confirm that you agree.* I Agree Please confirm that you are happy to receive my email newsletter with information about my classes and news about women's health and fitness.* Yes, I do want to receive your email newsletter No, I do not want to receive your email newsletter CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.