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Prenatal Intake Form

Personal Information

First name*

Last name*

Email*

Phone*

Emergency Contact*

Emergency Contact Number*

Pregnancy Information

Due Date*

Current Week of Pregnancy*

First Pregnancy?*

Yes

No

Vaginal birth or C-section previously?

Vaginal birth

C-section

Medical Clearance

I confirm that I have consulted with and/or received clearance from my healthcare provider to participate in prenatal fitness classes.

Current Symptoms and Conditions

dizziness

bleeding

high blood pressure

pelvic pain (PGP)

severe back pain

shortness of breath

contractions

gestational diabetes

other concerns

Please explain if applicable

Exercise Background

Have you practiced Pilates before?*

Yes

No

Current activity level*

Injuries or limitations*

I understand that prenatal fitness classes are not a substitute for medical care. I agree to inform my instructor immediately of any pain, discomfort, dizziness, bleeding, or unusual symptoms during class.

I have read and agree to the Dumaguete Wellness Participation Waiver & Release of Liability.:Waiver & Release of Liability

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