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Pregnancy Health Questionnaire

Please fill in the Pregnancy Health Questionnaire Form before attending you’re first class

Have you experienced any complications during this pregnancy?
Have you had any previous pregnancies?
If yes, have you experienced any complications during previous pregnancies or laboured before 37 weeks?
Have you been told you have any of the following?
Have you been told you have any of the following?
Are you experiencing any of the following symptoms?
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 problems 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
Keep me updated with Elysian News- Including class updates and offers
Yes Please
No thank you

By ticking this box, I confirm that all information provided in this questionnaire is true and accurate to the best of my knowledge. I understand that participation in any exercise program involves inherent risks, and I voluntarily choose to participate. I agree to inform my instructor of any changes in my health status and to stop exercising immediately if I experience any symptoms of distress or discomfort, notifying my instructor right away. My electronic signature serves as my legal confirmation of all information provided.

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