Street Address Line 2
State / Province
Postal / Zip Code
Date your baby is due :-)
Why have you decided to start Yoga/Pilates in pregnancy?
Type a question
What aspects of your health would you like to comcentrate on?
Pelvic Floor Training
What are your three main aims you'd like to achieve with your program?
Are you currently working? If so what is your occupation?
Does your job invlove any repetitive movements or prolonged postures? If yes, please explain briefly .
Are you involved with any other sports/hobbies? If yes please briefly explain?
Are you currently experiencing OR ever been diagnosed with any of the following?
Pain at the front / back of your pelvis
Any other muscle or joint conditions
High or low blood pressure
Circulatory problems, e.g. blood clots
Abnormal vaginal bleeding
History of spontaneous miscarriage
Abnormal placental function or position
Is this your first pregnancy?
If no, how many other children do you have and ages?
Have you ever had any complications with your pregnancy?
Have you had any episodes of low back pain?
Any recent injuries/surgeries?
I consent to participating in Wellfit Mumma Pregnancy Classes!
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