● Please delete either “Yes” or “No” to each question. Put an “X” in the appropriate column.
● If you answer “Yes” to any question, please give details in the spaces provided as appropriate.
If yes please enter your medication details in the box at the bottom of this form

I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with Claire Mockridge staff, my Doctor and/or postnatal healthcare team. I understand that any exercise program has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in the activities of personal training antenatal fitness classes, and will immediately discontinue any activity if I feel any symptoms of distress or discomfort, and will notify my instructor.

I understand and acknowledge that the instructors of Claire Mockridge are not Health or Medical Practitioners and therefore can not diagnose or treat individual health or medical problems. All such questions and concerns should be directed to my own Doctor and/or Midwife and I agree to do so.