Rose Hibberd Mother and Baby Health Check All details will be kept strictly confidential Your name (required) Email (required) Your date of birth (required) Your baby’s name (required) Your baby's gender (required) —Please choose an option—MaleFemale Your baby’s date of birth (required) Birth weight (required) Type of birth (required) Other information regarding the birth Have you had your postnatal health check (Yes/No) (required) —Please choose an option—YesNo Do you have any medical conditions (Yes/No) (required) —Please choose an option—YesNo If yes please give details Do you have any allergies (Yes/No) (required) —Please choose an option—YesNo If yes please give details Please outline any comments you may wish to share regarding your physical, mental and emotional state (all information is strictly confidential) Paediatric Check 6-10 weeks (Yes/No) (required) —Please choose an option—YesNo Does your baby have any medical conditions (Yes/No) (required) —Please choose an option—YesNo If yes please give details Has your baby been vaccinated? Please specify for what and when (required) Note reactions Does your child have any allergies (Yes/No) (required) —Please choose an option—YesNo If yes please give details Is your baby displaying any of the following: Vomiting (Yes/No) (required) —Please choose an option—YesNo Skin rash (Yes/No) (required) —Please choose an option—YesNo Infections (Yes/No) (required) —Please choose an option—YesNo Cuts/Wounds (Yes/No) (required) —Please choose an option—YesNo Diarrhea/Constipation (Yes/No) (required) —Please choose an option—YesNo Temperature/Fever (Yes/No) (required) —Please choose an option—YesNo Bruising/Swelling (Yes/No) (required) —Please choose an option—YesNo Scars/Inflammation (Yes/No) (required) —Please choose an option—YesNo Any other information Health check consent I give my consent for the information I have provided in this Health Check Form to be stored and accessed by the MamaBabyBliss Teacher with whom I have booked a class or workshop so that she may take into consideration any conditions that may be relevant to the class or workshop I wish to attend. I understand that this information will be kept securely on file for as long as I attend this class or workshop. Health check consent (Yes/No) (required) —Please choose an option—YesNo Photography disclaimer Occasionally photos may be taken in class. Please let us know if you give your consent to any photos being published in MamaBabyBliss marketing (Yes/No) (required) —Please choose an option—YesNo