prenatal registration form Name * First Name Last Name Email * Mobile * This number may be used to contact you about your booked classes. Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth Month/Date/Year MM DD YYYY GP's Name & Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about Beyond Move? What prompted you to take up Pilates with Beyond Move? What aspects of your health would you like to work on? Please select all answers that apply to you. Core Stability Flexibility Posture Pelvic Floor Relaxation Toning Other How many weeks pregnant are you now? When is your estimated due date? MM DD YYYY Are you currently working? If so, what is your occupation? * Does your occupation involve any repetitive movements or prolonged posture? If so, please provide brief details below. Are you involved in any other sports or physical activities? If so, please provide brief details below. Has your GP/Midwife agreed for you to carry out gentle exercises? * Yes No Are you currently experiencing, or have you ever been diagnosed with any of the following medical conditions? * Please select all answers that apply to you. Back Pain Pain at the back or front of the Pelvis Any other Muscular or Joint conditions Heart Problems High or Low Blood Pressure Blood Circulation Issues Diabetes Abnormal Vaginal Bleeding Pre-eclampsia Incompetent Cervix History of Spontaneous Miscarriage Anaemia Epilepsy Abnormal Placenta Function or Position None of the above Is this your first pregnancy? * Yes No If no, how many other children do you have, and what are their ages? Are you pregnant with multiples? Yes No Do you have any complications with your pregnancy? If so, please provide details below. * Have you ever had any episodes of lower back pain? If so, how many times have you experienced this? Have you had any recent injuries or surgery? If so, please provide details below. Pilates participation informed consent I have answered these questions to the best of my belief. I will inform my teacher if my medical condition changes in the future * Yes Thank you for submitting the Prenatal registration form. If you have any questions, or want to make changes to the form, please contact us at hello@beyondmove.com.
