Livewell | Harvest Pregnancy Screening

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)

Estimated Date of Delivery*

Where did you hear about Live Well Waterford:*

Medical Questionnaire

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

*

Please provide further details if you selected a condition above*

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:*

Please provide further information for any condition selected above. If other, please explain.*

Harvest LiveWell Mum-to-be Aims

Help us to help you! Tell us a little about why you have decided to pop along and join us at the Harvest!

Have you done pilates or yoga before?*

Please tell us more about any past experience of pilates or yoga. If you have never done pilates or yoga, please let us know about any other exercise you may have been involved in.

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

Core Stability
Flexibility
Posture
Pelvic Floor training
Toning
Relaxation

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.

Pilates Participation Informed Consent

The Mum-to-be class will begin at a low level and will be advanced in stages depending on your fitness level. 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 as I will be attending as part of a class, the exercise programme will not be specifically designed to my individual needs. Although, the class instructor will investigate to highlight any areas of personal weakness and suggest areas for self practice. I have been made aware of the indicators to stop exercising in relation to pregnancy and I will inform the instructor 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 attending a pregnancy exercise class and have given me clearance to attend.

Harvest Photography Informed Consent

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 Pregnancy Screening

Harvest Pregnancy Screening

General Client Details

Medical Questionnaire

Harvest LiveWell Mum-to-be Aims

Pilates Participation Informed Consent

Harvest Photography Informed Consent

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