Livewell | Harvest Core Restore

Harvest Event*

General Client Details

Name*

Date of Birth*

Address

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

Mobile Number*

Email*

GP Name and Address*

Obstetrician Name and Address*

Allocated Midwifes Name and Address (if known)

Date of Delivery*

Have you heard of LiveWell Waterford before?*

If yes, please tell us a bit more.

Have you previously attended classes or been recommended to attend the LiveWell clinic by anyone? If so, we'd love to hear who recommended us or where you may have seen us before.

Medical Questionnaire

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

*

Are you on any medication?*

If yes, please give details*

Was 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 pregnancy? Assisted delivery?*

Did you have a natural birth or C-section*

How many weeks post-natal are you?*

To exercise in the Harvest Mum & Baby Class, you must be at least 6 weeks post vaginal delivery and have had your GP 6 week check. If you had a c-section, you must be at least 10 weeks post delivery. If you are unsure at all, contact the LiveWell clinic.

Did you have a multiple birth?*

Did you have any of the following during, or as a result of, your pregnancy*

Symphsis Pubis Dysfunction
Diastasis Recti
DVT or other blood clot
Urinary Stress Incontinence
Prolapsed Bowel
Preeclampsia
NONE OF THE ABOVE

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

If other, please state:

What motivated you to book a space in this class?

Please take a moment to tell us about any expectations or hopes you have regarding the class. Is there anything you hope we cover with you in the classes. Are you looking for help regarding an a certain aspect of post-natal recovery?

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 hope to achieve by attending?*

Do you currently attend any exercise classes?*

Do you attend any other post-natal exercise class? Were you assessed by your instructor regards Diastasis Recti/tummy separation? Are you having any issues or queries about what exercises to do?

LiveWell Updates and Offers*

We like to give preferential booking notice and offers to previous attendees of LiveWell services. We also like to share information about workshops and classes. Please let us know if you would like to be kept on the LiveWell email list to receive this information.

Harvest Participation Informed Consent

This Harvest class will begin at a low level and will be advanced/modified within the class depending on your fitness level and ability. 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 by observations during exercise.

I understand that the Harvest Exercise Classes are specifically designed by the class instructor and will take into account details given in my health questionnaire. Therefore, this exercise should only be undertaken in a class setting, or when I have been given specific instructions to exercise on my own.

I have had my 6-week post-natal examination by my GP and have been cleared for exercise.

Please note that this is a Free Promotional Event. For publicity purposes, LiveWell Waterford and other Waterford Harvest Festival media partners, including local newspapers, may wish to take photos/videos during the scheduled events of the Harvest 'LiveWell' Day. This includes in the class setting. These photos/videos will be used for media purposes by LiveWell Waterford & Waterford Harvest Festival and on the LiveWell Website, publications and/or social media associated with LiveWell Waterford and/or the promotion of future Harvest Festival Events.

THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 1984.

I have read and agree to terms*

Live Well Waterford

Harvest Core Restore

Harvest Core Restore

General Client Details

Medical Questionnaire

What motivated you to book a space in this class?

Harvest Participation Informed Consent

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