Pregnancy Pre-Exercise Health and Lifestyle Questionnaire
Data Protection: The information that is provided on this form will be used by your trainer to plan your programme and to contact you. It will be kept on a computer database, accessible only to the trainer and her administrative assistant. In addition we request your permission below to add your name and email address to our database and to send you regular email newsletters. You will be able to unsubscribe from those newsletters at any time. Your name and email address will never be shared with any third party.
Date *
MM
/
DD
/
YYYY
Name *
Your answer
Address *
Your answer
Phone number *
Your answer
Email *
Your answer
Do you give us consent to send email newsletters to you? *
Programme start date
MM
/
DD
/
YYYY
Due Date / No. of weeks Pregnant
Your answer
Health Care Provider details
Your answer
Green Notes?
Your answer
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