Pre-Course Questionnaire

Before you start your classes with us we need to collect some information about you to ensure that we are looking after you and your babies. The information you disclose in this form with be viewed by your practitioner alone and will be stored in a locked filing cabinet.

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NameEnter full name
Date of birthSelect your date of birth
date_range
AddressEnter your address
Phone numberEnter your number
Emergency ContactEnter details
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Please answer the following questions as truthfully as possible
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you are attending Mum and Bump classes:
How many weeks pregnant are you?Enter weeks
Have you had any extreme symptoms during your pregnancy?Enter symptoms (if any)
If you are attending the Mum and Baby classes:
How old is your baby?Enter age
What kind of delivery did you have?Enter details
Have you suffered any complications post-delivery?Enter details (if any)

To the best of my knowledge I can confirm that the information I have shared is factually correct.  If there are changes to this I am responsible for sharing that information with my practitioner.

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