Name *

First Name

Last Name

No. baby *

1st

2nd

2+

GP/Midwife clearance to exercise *

Do you have any concerns related to your health that you feel may impact on your ability to exercise during your pregnancy? If the answer is yes please contact your main care provider to obtain clearance if you have not already done so. We may ask you to provide a letter before attending our class.

Yes

No

Level of activity prior to falling pregnant *

Not active

Fairly active

Extremely active

Have you experienced any of the following *

Please tick if so (please note not all of these conditions will prevent you from exercising with us, we just like to know so we can adapt the class for you if necessary)

Heart condition

Dizziness

Prolapse

Pelvic girdle pain

SPD

Placenta Previa

Abdominal Separation

Miscarriage

Vaginal Bleeding

Diabetes

Asthma

Epilepsy/Seizure

High Blood Pressure

Joint Pain

Chest pain

Incontinence

None of the above

Covid 19 Disclaimer *

I will ensure that I do not attend class if I develop any signs or symptoms of Covid 19 and if I do attend a aquanatal class and test postive for Covid 19 I will inform the instructor with immediate effect.

Yes

T & C *

I have read and understood the WomenFIT Covid terms and conditions of taking part in a WomenFIT class.

Yes

WomenFIT Agreement *

I confirm that the information I have given is correct and to the best of my knowledge. I am aware that I must feel able to exercise prior to the class and I will notify the WomenFIT instructor if I feel unwell at any time during the class. Whilst I am aware that every effort has been taken to ensure the class is suitable for prenatal women, I understand and agree that my participation and safety is my own responsibility within a WomenFIT class.

Yes