Pregnancy Pre-Screening Form Pregnancy Pre-Screening Form Pre-screening form for pregnancy classes. Name* First Name Last Name Email* Mobile Number*Partner's Name & Telephone*In case of emergency Your D.O.B* Day Month Year Due Date* Day Month Year How many weeks pregnant are you?*Doctor's Name & Practice* Health conditionsPlease tick if you have experienced any of the following during or after pregnancy: Any excessive or sudden swelling and water retention? Any skin rashes, open or unhealed cuts or bruises? Any history or blood clots or Thrombosis? Any extreme calf pain, swelling or redness? Any severe and chronic itching? Extreme high blood pressure – current and previous history? Any excessive thirst and urination? Any rapid or large weight gain while Pregnant? Any varicose veins or haemorrhoids? Current multiple pregnancy? History of miscarriages? Currently, or during previous pregnancies have you suffered any of the following conditions?Currently, or during previous pregnancies have you suffered any of the following conditions?: Symphysis Pubis Dysfunction (SPD)? Sacrum or SIJ Pain? Bleeding during pregnancy? Low Back Pain? Knee Pain? Carpal Tunnel Syndrome? Upper Back Pain? Separation of your abdominal muscles? Varicose Veins? Gestational Diabetes? Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Has anyone ever said you may have a prolapse? If you have ticked any of the above, please give further info here.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 CAPTCHACommentsThis field is for validation purposes and should be left unchanged.