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Pilates with Kate Drayton
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First name
Last name
Email
Phone
Birthday
Day
Month
Month
Year
How many weeks/months post partum are you?
Did you have a vaginal or C-section delivery?
C- section delivery
Vaginal delivery
Has your GP verified your health and confirmed that you are safe to exercise at the 6-8 week post natal check?
*
Yes
No
Not applicable
How many weeks pregnant are you?
What is your baby's due date?
Are you pregnant with more than one baby?
Yes
No
Do you currently have or in the past have you ever experienced any of the following medical conditions? Please tick the box if YES.
*
Heart condition or cardiovascular disease
Epilepsy
Diabetes that is not stable or your blood sugar is out of target ranges
mild. moderate or severe respiratory conditions e.g. asthma, COPD, chronic bronchitis
Joint condition / pain
High or low blood pressure
Chest pain
Allergies
Major surgery
Cancer
History of stroke
Liver disease
Kidney disease
Thyroid condition
Chest pain at rest or on exertion
Dizziness
Balance problems
Other chronic medical condition
Muscle, Joint or Soft tissue injury that could be made worse by exercise or physical activity
An eating disorder(s) or malnutrition
Option 21
Other
If you have answered YES to any of the above boxes regarding your medical history, and/or have any other health conditions, then please provide further details below. Please also state if this could affect your ability to carry out Pilates exercise.
Do you currently have any of the following pre and post natal conditions? Please tick if YES
*
Pelvic pain
Low back pain
Carpal Tunnel syndrome
Coccyx pain
Sciatica
Neck or upper back pain
Pelvic organ prolapse
Diastasis Recti (abdominal separation)
Shoulder pain
De Quervains tenosynovitis (mummy thumb)
High or low blood pressure
Bladder incontinence
Bowel incontinence
weak cervical tissue (incompetent cervix)
A stitch of tape to reinforce your cervix (cerclage)
A placenta that is partially or completely covering the cervix (placenta previa)
Unexplained bleeding, ruptured membranes or labour before 37 weeks
A baby that is growing slowly (intrauterine growth restriction)
High blood pressure (preeclempsia, gestational hypertension, or chronic hypertension that is not stable)
Low red blood cell number (anemia) with high levels of fatigue and/or light headedness
Gestational diabetes
In previous pregnancies had early delivery before 37 weeks
In previous pregnancies had recurrent miscarriages (loss of your baby before 20 weeks gestation two or more times)
Any condition that might affect your ability to be physically active during pregnancy
Other
None
If you have ticked any of the boxes above, or have any medical conditions related to your pre/post natal health, has a doctor verified that you are safe to exercise? If NO, please seek medical assurance that you are safe to proceed with exercise.
*
Yes
No
Not applicable
Are you currently taking any medication, if YES please list below.
Do you have any concerns about exercising whilst pregnant or in the post natal phase? If so, please comment below
*
Has a doctor ever told you that you should only do medically supervised exercise or physical activity only?
*
Yes
No
What are your reasons for practicing Pilates?
Improve core strength
Improve pelvic floor strength
Improve pelvic floor flexibility
Improve overall fitness
Improve overall flexibility
Meet other mamas
To move my body
To have fun
By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in Pilates. I also affirm that I alone am responsible to decide whether to practice Pilates and participation is at my own risk.
*
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By signing, I agree that if my physical health changes in any way that it is my responsibility to notify my Pilates instructor of these changes before continuing with exercise. I also acknowledge that a copy of this form will be retained for records.
*
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I have read fully & understand, & agree to the above terms of this Liability Waiver Agreement. I am signing voluntarily recognising that my signature serves as complete & unconditional release of all liability to the greatest extent allowed by UK law.
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