Rose Hibberd Pregnancy Bliss Health Check All details will be kept strictly confidential Your name (required) Email (required) Your date of birth (required) What is your Expected Due Date? (required) How has your pregnancy been? Are there any pre-conditions to be aware of? Is this your first pregnancy? (Yes/No) (required) —Please choose an option—YesNo If not, how old is/are your previous child/ren? (required) Any medical comment? Please list any common ailments you may be suffering from. Examples include back-ache, anxiety, sleeplessness, SPD, heartburn Medical History Are you taking any medication? (Yes/No) (required) —Please choose an option—YesNo Have you had any recent operations (including a C-section)? (Yes/No) (required) —Please choose an option—YesNo If yes, please state date of operation Have you been in any serious accidents? (Yes/No) (required) —Please choose an option—YesNo If yes, please state date of accident Do you suffer from any of the following symptoms? Gynaecological Have you suffered from any bleeding? (Yes/No) (required) —Please choose an option—YesNo If yes, have you sought advice from your midwife/GP? Cardiovascular Chest pain? (Yes/No) (required) —Please choose an option—YesNo Shortness of breath? (Yes/No) (required) —Please choose an option—YesNo Palpitations? (Yes/No) (required) —Please choose an option—YesNo Do/did you smoke? (Yes/No) (required) —Please choose an option—YesNo If yes, please specify number of cigarettes a day Respiratory Cough (Yes/No) (required) —Please choose an option—YesNo Asthma (Yes/No) (required) —Please choose an option—YesNo Gastro-intestinal Any changes in bowel habits? (Yes/No) (required) —Please choose an option—YesNo Constipation (Yes/No) (required) —Please choose an option—YesNo Diarrhoea (Yes/No) (required) —Please choose an option—YesNo Nausea (Yes/No) (required) —Please choose an option—YesNo Urinary Any problems passing water, starting or stopping? (Yes/No) (required) —Please choose an option—YesNo Burning (Yes/No) (required) —Please choose an option—YesNo Changes in frequency (Yes/No) (required) —Please choose an option—YesNo 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