Livewell | Post-natal screening

Session*

General Client Details

Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number*

In case of emergency CONTACT NAME & NUMBER*

Email*

GP Name and Address*

Obstetrician Name and Address*

Allocated Midwifes Name and Address (if known)

Date of Delivery*

Were you referred by a medical/health professional?*

If not, where did you hear about Live Well Waterford Pilates:*

Medical Questionnaire

Are you currently experiencing OR ever been diagnosed with any of the following conditions?

*

Are you on any medication?*

If yes, please give details*

Was this your first pregnancy?*

If no, how many other children do you have and what are their ages?*

Did you have any complications with your pregnancy? Assisted delivery?*

Did you have a natural birth or C-section*

How many weeks post-natal are you?*

Did you have a multiple birth?*

Did you have any of the following during, or as a result of, your pregnancy*

Symphsis Pubis Dysfunction
Diastasis Recti
DVT or other blood clot
Urinary Stress Incontinence
Prolapsed Bowel
Preeclampsia
NONE OF THE ABOVE

Which, if any, of the following conditions have you been diagnosed with or had treatment for:*

If other, please state:

Pilates Aims

Why have you decided to commence pilates after pregnancy?*

What aspects of your health would you like to concentrate on?

Core Stability
Flexibility
Posture
Pelvic Floor training
Toning
Relaxation

What are the three main aims you are hoping to achieve with Pilates?*

Pilates Participation Informed Consent

The Pilates programme will begin at a low level and will be advanced in stages depending on your fitness level. We may stop the exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort.

There exists the possibility of certain dangers when exercising; abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of the preliminary information you provide in this form and by observations during exercise.

I understand that as I will be attending as part of a class, the exercise programme will not be specifically designed to my individual needs. Although, the class instructor will investigate to highlight any areas of personal weakness and suggest areas for self practice.

I have had my 6-week post-natal examination by my GP and have been cleared for pilates exercise. If post Caesarian Section, I confirm that I am a minimum of 10 weeks post surgery and have been cleared for exercise by my surgeon or GP.

Please note that refund payments will not be given for unattended classes.

I have read and agree to terms*

Live Well Waterford

Post-natal screening

Post-natal Screening

General Client Details

Medical Questionnaire

Pilates Aims

Pilates Participation Informed Consent

Classes

Treatments

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