Name

Address

Postcode

Telephone Number

Mobile Number

Email

Name of Doctor

Doctor’s Telephone Number

Emergency Contact Name and Telephone Number

Class

Ante Natal

Post Natal

If Ante - Due Date

Current Weight

Weight Prior to Pregnancy

Where would you like
to join the class? Please select a location Roundwood Health Clinic, 110 Dodworth Rd, Barnsley S70 6HL Gosling Sports Park, Stanborough Road, Welwyn Garden City, Herts AL8 6XE Hertfordshire Sports Village, de Havilland campus, Hatfield Business Park, Hatfield, Hertfordshire AL10 9EU Methodist Church Hall, Silver Street, Stony Stratford, Milton Keynes MK11 1JS Fitness First, Skimpot Road, Luton, LU4 0JB 1. The Letchworth Centre for Healthy Living, Rosehill Hospital, Hitchin Rd, Letchworth, Hertfordshire SG6 3NA 2. Fitness First, Great North Road, Roaring Meg Retail Park, Stevenage, SG1 1XN CityGym, 2 Furness Road, Eastbourne Chase Fitness, Church Chare, Whickham, Gateshead, Newcastle-upon-Tyne NE16 4SH Studio 2, Craiglockhart Tennis & Sportscentre, 177 Colinton Road, Edinburgh EH14 1BZ Ponteland Leisure Centre, Ponteland, Newcastle NE20 Fitness First, The Highstreet, Uxbridge, London. UB8 1GD Performers Physiotherapy, Performers College, Southend Road, Corringham, Essex, SS17 8JT Central Newcastle High School, Chapman House, Sandyford Road, Newcastle upon Tyne NE2 1TA

Gymball & Pump
To enable you to continue your exercises at home we recommend that you use gym balls of anti-burst quality for your safety. These can be purchased and supplied to you at a cost of £15 (rrp £25) at the time of your booking. They come in various sizes and strengths depending on your height and body weight.

Do you require and anti-burst gym ball?

Yes No

If yes, please state your height

If yes, please state your weight

Please list any past medical problems diagnosed

Exercise

Did you exercise regularly prior to becoming pregnant?

Yes No

Have you exercised during pregnancy?

Yes No

Please provide details.

Is this your first Pregnancy?

Yes No

Have you ever suffered miscarriage in any previous pregnancies, vaginal bleeding or other complications?

Yes No

Please provide details.

Is your pregnancy going well - are you having any medical treatment for complications in your pregnancy?

Yes No

Please provide details.

Please answer the following carefully

Do you or have ever you ever been diagnosed with any of the following:

Symphasis Pubis Dysfunction ?

Yes No

Serious heart, respiratory, renal or thyroid disease

Yes No

Type 1 or Type 2 diabetes

Yes No

Asthma

Yes No

Anaemia

Yes No

Epilepsy

Yes No

Swelling in hands, ankles or face

Yes No

High or Low Blood Pressure - Preclampsia?

Yes No

Urinary tract, bladder or kidney infection - in the last year?

Yes No

Do you suffer any problems in controlling urination?

Yes No

Have you been diagnosed with extreme obesity?

Yes No

Are you on any medication?

Yes No

Do you smoke?

Yes No

Do you consume alcohol?

Yes No

If you answer yes to any of the questions detailed above, please provide details.

Where did you hear about us? Word of Mouth Doctor Internet Physiotherapist Local hospital Leaflet Midwife NCT Health visitor

PLEASE NOTE: You must agree to the client disclaimer below before participating in our classes. Please read and tick in the box provided before submission.

Every precaution will be taken by our instructors to ensure your safety. With that in mind, you are aware of the nature of the classes and any risks involved. You acknowledge that certain elements of the classes will be physically demanding. You agree that you are physically capable of participating in the sessions and accept full and complete responsibility for your own participation in the class. You agree that should any medical or physical arise prior to or during a class which is likely to affect your ability to participate in a class that you will not attend / withdraw. FitBack & Bumps liability for personal injury, death or loss or damage to property is limited to any damage or loss suffered as a direct result of the negligence of FitBack & Bumps or its instructors. FitBack & Bumps shall not be liable to you for any indirect or consequential loss or damage including loss of earnings arising out of your participation in classes nor for an aggregate amount greater than the fee paid for the classes. If there is anything else we need to know regarding your health & fitness, please provide details above in the Prescreen Medical Questionnaire.

I agree to the terms and conditions stated above

Do you give your permission for FitBack & Bumps to contact you by email once you have completed your class?

Yes No