Register - Ira May Fitness

Participant Information

Name *

Email *

Address *

Post Code *

Home Phone *

Work Phone *

Mobile *

Your Birth Date *

Emergency Contact Details

Emergency Contact *

Relationship to you *

Phone number(s) *

Which hospital are you booked into? *

Who is your midwife? *

Who is your regular doctor? *

Who is your obstetrician? *

How did you hear about Ira May Aquanatal Canberra: *

Pregnancy & Birth History

Baby’s due date *

Baby’s birth date (if post-natal) *

Twins? *YesNo

First baby? *YesNo

Did you experience any pregnancy or birth complications in earlier pregnancies? *YesNo

If not your first, the number of your previous pregnancies: *

Yes? *

Is there anything else you feel your instructor should know? *YesNo

Are you experiencing any pregnancy-related problems now ? *YesNo(e.g. marked fatigue, spotting, abdominal or groin pain, sudden swelling in ankles/hands, headaches, back pain, pain when walking, ligament pain, varicose veins, etc.)

Yes? *

General Health and Fitness

Do you have any current general medical problems? *YesNo(e.g. asthma, diabetes, heart trouble, arthritis, high blood pressure, etc.)

Do you have relevant past medical problems? *YesNo

If Yes, What? *

Were you exercising regularly prior to this pregnancy? *YesNo

what were you doing? *

About how many sessions per week? *

Are you exercising regularly during this pregnancy? *YesNo

what were you doing? *

About how many sessions per week? *

What is your regular occupation? *

Can you comfortably swim 25 metres? *YesNo

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