MOMA BUMPS PRENATAL PROGRAMME

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Congratulations on your pregnancy! Thank you for taking the time to fill out this form. It's important that you give as much detail as you can so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and beyond! Thanks Goretti

This information will help us to design the appropriate programme for you.

All information contained within is strictly confidential and will not be shared with a third party. By completing this form you are giving consent for us to store your data.
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Your Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Day
Month
Year
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E-mail* This field is required.
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Contact Number* This field is required.
Area Code
Phone Number
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Do you give consent to be contacted by Roscommon Pilates/Pilatesnow.ie?* This field is required.You may change your mind and unsubscribe from our contact lists at anytime
YESNO
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Where did you hear about us?* This field is required.FB, Insta, health pro, word of mouth?
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Hospital for Delivery* This field is required.Which hospital are you attending or homebirth?
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Estimated Due Date* This field is required.
Day
Month
Year
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About your health
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Please state your general health* This field is required.
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Do you have any allergies I should be aware of?
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Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.* This field is required.
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Have you suffered miscarriage in any previous pregnancies, vaginal bleeding or other complications?* This field is required.
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Are you or were you active in sports, exercise programmes, physical activity etc before pregnancy and now? Please describe
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Do you currently have any of the following?
Serious heart, respiratory, renal or thyroid disease
Asthma
Type 1 or Type 2 diabetes
High or Low Blood Pressure
Epilepsy
Anaemia
Swelling in hands, ankles or face
Back, neck or knee problems
Pregnancy Related Pelvic Girdle Pain
Symphasis Pubis Dysfunction
Urinary tract, bladder or kidney infection in the last year
Problems in controlling urination
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If you ticked yes to any of the health conditions questions above please provide details
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Have you given birth before?* This field is required.
No
Yes,Vaginally only
Yes, Cesarean only
Yes,Vaginally and Cesarean
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Any other questions or concerns?
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Which Programme do you wish to join?* This field is required.Select one
Weekly In Person classes in Roscommon Pilates Studio
Pre-recorded On demand with PilatesNow.ie
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I would like to be added to the BUMP CREW Whats App Group* This field is required.You may opt out at any stage
Yes please add me
No thanks
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Please read the following for your information

Prenatal Pilates classes will begin at a low level and will be advanced in stages. If you experience any fatigue, discomfort or weakness, please stop, rest and inform your instructor. Although we would encourage active participation and enthusiasm, please do not feel you have to participate in every exercise if you feel you are unable to - Listen to your body! Please be aware of the following warning signs to stop exercising when pregnant:

VAGINAL BLEEDING

SHORTNESS OF BREATH

DIZZINESS

HEADACHE

CHEST PAIN

CALF PAIN OR SWELLING

AMNIOTIC FLUID LEAKAGE

What to bring to class?

Yoga mat

Gym ball (Under 5’2” 55cm diameter, 5’2” – 5’9” 65cm diameter, Over 5’9” 75cm diameter)

Comfy clothing

Water to drink and snack if required (eg fruit, nuts, crackers etc)
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* This field is required.
I have read and understood the the terms and wish to proceed
I have read and understood the terms and do not wish to proceed
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PILATES PARTICIPATION INFORMED CONSENT

You must agree to the client disclaimer below before participating in our classes. Every precaution will be taken to ensure your safety during participation in these classes. With that in mind, you are aware of the risks involved. You agree that certain elements of the classes will be physically demanding. You agree that you are physically capable of participating in the sessions and accept full and complete responsibility for your own participation in the class. You agree that should any medical or physical problem arise prior to or during a class which is likely to affect your ability to participate in a class you will inform the Instructor and discuss.

I agree to the terms and conditions stated above. My GP and/or Obstetrician are aware that I am commencing Prenatal Pilates and have given me clearance to attend.
Should be Empty: