Livewell | Ante-natal screening

Session*

General Client Details

Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number*

In Case of Emergency Contact Name & No.*

Email*

GP Name and Address*

Obstetrician Name and Address*

Allocated Midwifes Name and Address (if known)

Estimated Date of Delivery*

Were you referred by a medical/health professional?*

Details of Health Professional:

Where did you hear about Live Well Waterford:*

Medical Questionnaire

Are you currently experiencing OR ever been diagnosed with any of the following conditions?

*

Is this your first pregnancy?*

If no, how many other children do you have and what are their ages?*

Did you have any complications with your previous pregnancy/pregnancies?*

How many weeks pregnant are you?*

Have you had any complications with your pregnancy?*

If yes, please specify*

Are you expecting a multiple birth?*

Have you ever had an episode of Lower back pain?*

If yes how many previous episodes of Lower back pain have you had?*

Did you exercise before pregnancy?*

If yes, briefly outline please:*

Have you been exercising during this pregnancy?*

If yes, please provide details:*

Which, if any, of the following conditions have you been diagnosed with or had treatment for:*

If other, please state:*

Pilates Aims

Why have you decided to commence pilates/physiotherapy during this pregnancy?*

What aspects of your health would you like to concentrate on?*

Core Stability
Flexibility
Posture
Pelvic Floor training
Toning
Relaxation

What are the three main aims you are hoping to achieve by attending Live Well Pilates/Physiotherapy?*

I have read and agree to terms*

Pilates Participation Informed Consent

For live classes, the Pilates programme will begin at a low level and will be advanced in stages depending on your fitness level. Online, the classes have been designed with modifications and progressions and it is up to you to follow advice given and to stop if unsure or feeling unwell/any pain. In live classes, we may stop the exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort.

There exists the possibility of certain dangers when exercising; abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of the preliminary information you provide in this form and, if attending a live class, by observations during exercise.

For live classes and online classes: I understand that as I am attending as part of a class or via the online platform, that the exercise programme will not be specifically designed to my individual needs. Although, in a live class, the class instructor will investigate to highlight any areas of personal weakness and suggest areas for self practice. Online via the LiveWell Women Platform, I am aware of the health and safety disclaimer and have read fully. This disclaimer is available to view in the downloads section beside all videos. I have been made aware of the indicators to stop exercising in relation to pregnancy and I will inform the instructor/LiveWell if any such symptoms occur. The warning signs to stop exercising when pregnant include: vaginal bleeding, shortness of breath, dizziness, headache, chest pain, calf pain or swelling, amniotic fluid leakage.

My GP and/or Obstetrician are aware that I am commencing pregnancy pilates exercise and have given me clearance to attend.

Please note that refund payments will not be given for unattended classes.

Live Well Waterford

Ante-natal screening

Ante-natal Screening

General Client Details

Medical Questionnaire

Pilates Aims

Pilates Participation Informed Consent

Classes

Treatments

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