Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Emergency Contact Name * First Name Last Name Emergency Contact Number * Have you recently had a baby? * Yes No How old is your baby? * 0-6 months 6-12 months over 12 months Are you taking any medication? * Are you generally fit and healthy? * Yes No Did you have a C section? If so how is your scar? * Pelvic Floor - If you run, jump or sneeze are you unable to control your bladder when doing exercise? * Yes No Sometimes About your delivery - This is important in relation to your pelvic floor. * N/A Assisted Foreceps Vontuse Did you tear during delivery? * Yes No Have you been checked for Diastases Recti - Have your abdominals "closed" back up or can you still feel a gap between your abdominals? * Yes No Are you struggling with your back since giving birth? * Yes No Are you breast feeding? * Yes No Have you had a hysterectomy? * Yes No Have you had a prolapse? * Yes No Post natal bleeding- Are you still bleeding after birthing? If you are still bleeding weeks after giving birth this could make you anaemic or suggest there is still parts of the placenta that have not be removed. * Yes No Sometimes Early post natal - Do you bleed after exercise? - If so you need to go back to your GP * Yes No Having a baby is life changing - I like to ask how you are feeling emotionally and your mental health state? * Are there any other relevant medical conditions that I should know about? * Please don't feel you have to come along and have a hard workout, if you are coming to the class and just joining in, being with a lovely group of people, getting outdoors with your pram and baby is all you can manage then that's wonderful! Please just come along and join in at a level that suits you. You'll be amazed how fabulous it will help you feel. Wrap up and bring a matt and a drink, PLUS your baby bag and spread the word the more the merrier! Do you have any questions? * Thank you!
