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    date of birth

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    Your partners name

    Your Partner's Address

    Your partner's/ emergency contact number

    Enter Your Baby's Name

    Your baby's date of birth

    Your Occupation

    Your Doctors Name

    Your Midwife's Name

    Your Doctors Telephone Number

    exercise previously taken

    How many other children do you have

    Shortness of breathHeart DiseaseDiabetesChest PainHypo GlycaemiaMultiple BirthsMiscarriagePelvic/Abdominal CrampsHigh blood PressureEating DisorderVaginal BleedingKnee problemsVaginal DisorderArthritisBack problemsBlood DisorderDizzinessNeck Problems

    Please select if you have experienced any of the above

    Is there anything else in your medical history that could affect your ability to exercise?

    Please give details of any medication taken

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    Please give details of any relevant concerns

    Please list your primary reasons/goals here

    What Type of Delivery did you have?

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    Detail any other exercise you are currently doing

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    Please read and sign

    I, acknowledge and confirm that I have had the all clear by my GP to commence suitable postnatal exercise. I am aware that I must feel well prior to each class and will notify you (the trainer) should I feel unwell at any time during the class.

    Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for postnatal women. I understand that my participation and the safety of both my child/children and myself are my responsibility. I shall inform my Buggyfit instructor of any medical or post-natal related changes prior to commencing each training session and that neither the instructor or Buggyfit will be liable in any way for any unforeseen circumstances nor for any circumstances of which I should have been aware but failed to notify them.

    Please be aware we do not advocate running with a buggy at Buggyfit.

    Social media is a great promotional platform for us- We may take informal photos or video at class to help with our promotion, but we respect your wishes so please delete appropriately.

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    Data Protection: The information you have provided here will be used for Buggyfit® purposes only by your Instructor/Trainer, we understand that some data in sensitive and treat this the way of a medical practitioner no data will be shared with any third party without your prior permission.

    I hereby consent for you to process and store my information for at least 7 years for professional and legal purposes and my consent will be sought before it is shared with anyone outside of Buggyfit®. However I understand that these details may be shared in the event of a medical emergency.

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    I confirm that all statements on the form are correct and that I have read and understand this declaration.