Pregnancy Health Questionnaire Please fill in the Pregnancy Health Questionnaire Form before attending you’re first class Email * Name * First Name Last Name How many weeks pregnant are you? * Is this a... * Single Pregnancy Twin Pregnancy Triplet Pregnancy Have you experienced any complications during this pregnancy? * Yes No If yes, please give details below Have you had any previous pregnancies? * Yes No If yes, have you experienced any complications during previous pregnancies or laboured before 37 weeks? Yes No If yes, please give details below Have you been told you have Severe anaemia Interuterine growth restriction (baby is growing slowly) Incompetent cervix (weak cervical tissue) Placenta Previa Pre-eclampsia Respiratory or Cardiovascular disease Type 1 diabetes that is unstable or outside of target ranges Ruptured membranes (unexplained bleeding) Epilepsy that is not currently stable Have you been told you have Anaemia Hyperthyroidism High/Low BMI Hypertension Are you experiencing any of the following symptoms? Nausea Dizziness Short of breath If you are experiencing other symptoms not listed above, please specify Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you perform physical activity? * Yes No In the past month, have you had chest pain at rest? * Yes No Do you ever lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Yes No Are you currently taking any medication we should be aware of? * Yes No Do you know of any other reason why you should not partake in physical activity? * Yes No Have you ever had any injuries, surgeries, or medical procedures (eg back surgery, joint replacement) * Yes No Are you currently experiencing any pain or discomfort? * Yes No Do you have any other medical conditions not mentioned? (Eg asthma, diabetes, arthritis, epilepsy, hernia, circulation problems?) * Yes No If you answered YES to any of the questions above. Please give details below: Do you have any allergies? (if yes, please specify) Emergency Contact Details * First Name Last Name Emergency Contact Number * (###) ### #### * I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with my instructor. I understand that any exercise programme has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in the class, and will immediately discontinue any activity if I feel any symptoms of distress or discomfort, and will notify my instructor. Please print name and date electronically below. I Agree Name * First Name Last Name Date * MM DD YYYY Add me to the EMBA Monthly Newsletter Yes No Thank you for submitting your Health Questionnaire. We look forward to seeing you at the studio!
