Pre-Natal Medical Forms | Sussex Reformer Pila

First name

Last name

Email

Phone

Which trimester are you currently in?

First Trimester

Second Trimester

Third Trimester

Due date:

Is this your first pregnancy?

Yes

No

If not, how many previous pregnancies have you had and were there any complications?

Have you experienced any miscarriages?

If so, please provide details:

During this pregnancy, have you experienced any of the following?

If you have ticked any of the above, please provide details:

What exercise/activity have you been doing so far throughout your pregnancy?

Have you told your doctor/midwife that you are beginning Pilates?

Yes

No

I confirm the information I have given is accurate and I will inform my instructor if I have any changes in my current circumstances.

Today's Date

Day

Month

Year

Signature

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Pre-Natal PAR-Q