Post Natal Programme Consultation Form This information is sent in the strictest confidence to our Pre/Post Natal specialist, Kate Faison. We will get in touch within 24 hours. Name First Last Date of birthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email OccupationMobile numberDate of birthDate of deliveryHeightWeightEmergency contact name & mobile How did you hear of us A personal recommendation TV / Newspaper / Magazine Public event / talk Google search Instagram (@teamdanroberts) Instagram (@Methodology_x) Facebook / Twitter / Pinterest Methodology X Group class Advertisement Previous births and extra infoPlease attach additional info: Date of previous births, type of birth + any additional notes associated with the pregnancy, delivery or post-natal recovery.Do you suffer from any of the following? ME High blood pressure Low blood pressure Diabetes Disordered eating BDD ADHD Raised cholesterol Anxiety Liver or Kidney conditions Digestive problems Any heart condition Epilepsy Hernia osteoporosis Arthritis Asthma Cramps Muscular pains Do you smoke?NoOccasionally40+ a weekHow much do you drink?Occasionally10+ units most weeks25+ units most weeksWhat medications are you on? Do you have any infectious diseases?NoYesHave you been recently hospitalized? (excluding giving birth)NoYesWaiver of Liability: Please scroll through fully and TYPE your name at the end.*We assume no liability for persons injured following our post-natal exercise or nutrition advice. If any medical or other conditions arise that could affect your training with us, you shall let us know immediately by email. If you have any doubts, please consult your doctor prior to physical activity. All exercise, nutritional and well-being advice given to you by Kate Faison, and any persons directly associated with Dan Roberts, Dan Roberts Training Ltd & Dan Roberts Enterprises Ltd is taken at your own risk. By typing your name and today's date after this statement you agree by these terms. This is required. Please type your full name and date right here....DELETE THIS AND TYPE YOUR NAME & DATEPlease read and sign aboveDid you type your name and date the liability waiver above?* Yes What type of birth did your baby have?VaginalC-SectionAre you breastfeeding?YesNoHow much weight did you gain from your last pregnancy?Have you or are you currently experience any urinary incontinence (urine leakage)? This is important for us.yesNoDid you workout prior to your pregnancy? What type of workouts did you like to do?Did you workout during your pregnancy, if so what kind of exercise did you do?What are your primary goals?Why are these goals important to you?What other fitness and wellbeing goals do you have?What are your expectations?Which exercises/activities do you love doing and why?Do you want help with nutrition?No thank youMaybeDefinitelyDo you want help with stress?No thank youMaybeDefinitelyDo you want help with body image?No thank youMaybeDefinitelyAre you currently working with any other health professionals (Physiotherapists or Nutritionists)?Is there anything else we should know?Do you have any specific questions for Kate?