Medical Form Name * First Name Last Name Email D.O.B MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Occupation (if applicable) How did you hear about us Facebook Instagram A Friend Flyer GP/OB/Physio Referral Emergency Contact 1 First Name Last Name Phone (###) ### #### Emergency Contact 2 First Name Last Name Phone (###) ### #### Medical Practitioner: Name & Number Obstetrician/Care Giver Hospital Selected For Birth Medical History - Have you experienced? Abnormal Blood Pressure (high/low) Respiratory Disease (Asthma/Bronchitis) Kidney Disease Chest Pain/Palpitations Neck Pain Faintness/Dizziness Muscular/Skeletal Injury Anaemia Recent Surgery/Illness None If you selected any of the above please provide details: Other problems that may effect ability to exercise: Are you taking any Medication? Yes No Medication Details: Lifestyle - Do you smoke? Yes No If so how many? Do you consume alcohol? Yes No If so how often? Pregnancy Details Was this your first pregnancy? Please also add DUE DATE: Type of birth C-Section Vaginal If no, how many pregnancies have you experienced previously? If applicable add ages of your children. Have you had miscarriages in the past? If yes, please provide details Did you have any pregnancy complications? If yes, please add details. How did you feel during any previous pregnancies? Are you currently breastfeeding? If no, when did you stop (this affects the amount of relaxin in your body) Are you currently experiencing any of the following? *If you experience any of the above during pregnancy please let the trainer know immediately Excessive Fatigue Vaginal Bleeding Unhealed Perineum Incontinence Anaemia Back Pain Abdominal Separation Dizziness/Faintness Abdominal Pain None Exercise History Were you exercising prior to pregnancy? If yes - provide details - type/frequency Did you exercise DURING pregnancy? If yes - provide details - type/frequency Are you currently exercising? Yes No Add current exercise details What type of exercise do you enjoy? Describe your eating patterns i.e what do you eat in an average day & how often What do you want to achieve by doing the Active Mum Program? Acknowledgment and Release * I the undersigned acknowledge that: This exercise program has been specifically designed for pregnant & postnatal women by Active Mum Pre & Post Natal Exercise Specialists In normal circumstances, the exercises should not harm me or my baby/toddler in anyway. I have discussed exercise with my practitioner and have been given permission to exercise. I have provided a letter from my practitioner of any concerns, relevant issues and special guidelines my Practitioner has in regard to my exercise program. Active Mum and its employees & contractors will not be liable in any way for any unforeseen circumstances or for any circumstances of which I (the participant) should have been aware, but failed to notify Active Mum I give permission to Active Mum and its employees & contractors to contact any of the emergency contact numbers set out above should the need arise. I have read the above statement and agree to be bound by it and to Active Mum and its employees and contractors from all claims. I AGREE Thank you!
