Pregnancy & Post Natal Registration
Please fill in this form prior to your first class. If any of this information changes while you’re attending classes please let your teacher know. All information given will be kept in the strictest confidence. Thank you!
Which course have you booked to attend? *
Full Name *
Your answer
Contact phone number *
Your answer
Email *
Your answer
Name of partner or other relevant contact: *
Your answer
Phone number for partner or other relevant contact *
Your answer
Date of birth (mother) *
Your answer
Due date or birth date of baby *
Your answer
Have you had any previous pregnancies? *
Have you had any previous births? *
If so, please state ages of your children
Your answer
Do you have any previous injuries or conditions or have you undergone any surgery which you think may affect your practice? *
Please give details of any previous injuries, conditions or surgery.
Your answer
Are you taking any medication that may have some bearing on your exercise class? *
Please give more details of medication.
Your answer
Why have you come to this class and what do you hope to gain from it? *
Your answer
How did you hear about this class? *
Pregnancy Class Only
If you are wishing to attend the pregnancy class please answer the following question, then scroll to the bottom of the page and submit. You may ignore the questions referring to the post natal class.
Do you have any specific problems arising from your pregnancy at this time
Post Natal Class Only
If you are wishing to attend the postnatal class please answer the following questions about the birthing experiences for this baby.
Length of labour in total:
Your answer
Length of first stage labour:
Your answer
Length of second stage labour:
Your answer
Was labour?
Nature of delivery?
Delivery environment?
Name of midwifery team providing ante/postnatal care:
Your answer
Any drugs administered during labour?
Any damage to perineum suffered?
Any stitches required following tearing/ episiotomy?
Any post-partum haemorrhage?
Was your baby?
At what stage was the umbilical cord cut?
Your answer
Weight of baby at birth?
Your answer
What was the state of health of baby at and immediately after birth?
Your answer
Since the birth of this baby have you experienced any of the following?
Has your baby experienced any of the following?
Submit
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