Name *

First Name

Last Name

Date of birth (month first)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Baby Date of Birth (month first) *

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Have you had any of the following?

Click all that apply

Antenatal incontinence

Prolonged 2nd stage labour

Multiple birth

Are there any conditions that you suffered with during your pregnancy?

Pelvic Girdle Pain

Carpal Tunnel syndrome

Pre-eclampsia

Back ache

Sciatica

Hypertension

Oedema

Diabetes

Terms and conditions

IF YOU ANSWERED YES to one or more questions*: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. IF YOU ANSWERED NO to all questions: You can be reasonably sure that it is safe for you to participate in physical activity, gradually building up from your current ability level. ------- “I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury”. *Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise. PLEASE ENTER TODAY'S DATE (month first)

MM

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