Pregnancy Exercise Screening - for Carly at www.projecthb.co.uk
Please complete all parts of this form and be prepared to provide further details, prior to attending a class or commencing an exercise programme with me.  

Why collect this data? Collecting information about your current health and fitness levels and about your pregnancy. By completing this form you are agreeing to accept the risks of physical exercise, meaning my professional indemnity and public liability insurance is valid, which I need in order to teach you safely and legally. I reserve the right to refer you or decline to take you on as a client dependent on the answers you give on this form. I will offer full explanations about my decision if this decision is made. The contents of this form,  protects us both.
 
What do I do with your data? I store form securely for 3 years from the day you signed last attended an exercise session with me, upon which point your data will be permanently deleted. If you want me to delete your data before this cut off time, please email me at projecthb@live.co.uk requesting this, and I will delete all data I have stored about you, immediately.

Please note: You may need to complete this form again, for a number of reasons, including updated info following an appointment with your midwife or consultant, or if you request I delete your data and then want to attend another class.  
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Full name *
Email address *
Phone number *
How did you hear about my classes? *
Emergency contact name & relationship to you *
Emergency contact telephone number *
Name of doctor and GP surgery *
GP surgery telephone number *
Are you pregnant? *
Is this your first pregnancy *
How many weeks pregnant are you? *
Have you had your first appointment with a medical professional yet? *
Is your pregnancy midwife or consultant led? *
Has your medical professional (midwife, GP, doctor, consultant) given you expressed permission to exercise? *
Have you experienced, or do you have a family history of any of the following? (ACs) *
Required
Have you been told by a medical professional that you are experiencing/have experienced any of the following during your pregnancy (or during a previous pregnancy)? (ACs) *
Required
Tick if you have you noticed or experienced any of the following symptoms during your pregnancy? (RCs) *
Required
Please tick 'yes' or 'no' for all of the following *
Yes
No
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 your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Is there anything else you'd like to disclose about your health or your pregnancy? *
GIVING CONSENT TO PARTICIPATE: Please read the following statement and type your name at the beneath, if you agree.
Subject to further conversation and prior to beginning an exercise programme with Carly Wilkinson, I, the undersigned understand the exercise session that I will perform and the associated risks and discomforts. Knowing these risks and discomforts, having understand and accept that I am free to cease exercising at any point during the session and that I have the opportunity to ask questions throughout. I consent to participate in this exercise session. *
Date signed *
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