Participant full name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your date of birth *

MM

DD

YYYY

Emergency contact name *

First Name

Last Name

Where are you planning to birth your baby? *

I have already birthed my baby

Homebirth

Northern Beaches Hospital

Royal North Shore Hospital

North Shore Private Hospital

The Mater

Sydney Adventist Hospital (The San)

Other

Who is your primary carer in pregnancy? *

I have already birthed by baby

Midwifery-led care (includes private midwife, midwifery group practice/caseload, hospital midwifery care and GP shared care models)

Private obstetrician (see additional question below)

Public obstetrician/high risk clinic

Estimated due date of your baby OR date of birth of your baby *

MM

DD

YYYY

Are you currently experiencing any of the following conditions: *

Back pain

Pelvic girdle pain

Urinary incontinence/pelvic floor issues

Gestational diabetes

Carpel tunnel syndrome

Anaemia

Low iron

Low blood pressure/dizziness/light headed

Other (please detail below)

No/none

PRE-EXERCISE SCREENING: The RANZCOG^ guidelines recommend that assessment of medical and obstetric risks should be undertaken to identify potential contraindications to exercise for pregnant women prior to commencing an exercise program. The following questions relate to this recommendation for pregnant women and for women who have birthed their babies. Please indicate by selecting the box(es) if you currently have any of the following conditions^^: *

Cardiovascular disease

Chronic respiratory disease

Placenta praevia

Persistent bleeding

Poorly controlled asthma

Poorly controlled thyroid disease or symptomatic anaemia

Poorly controlled seizure disorder

Poorly controlled diabetes

Type 1 diabetes

Pregnancy-induced hypertension or pre-eclampsia

Bone or joint problems that may be made worse by physical activity

Increased risk of premature labour (multiple pregnancy, ruptured membranes, premature contractions or shortened cervical length)

Fetal growth restriction

History of spontaneous miscarriage, pre-term labour or fetal growth restriction

Malnutrition, significantly underweight or eating disorder

Another significant medical condition

None of the above

Can you comfortably swim 25 metres? *

Yes

No, but I am comfortable participating in these classes (please note, the water depth from the bottom of the pool to the top of the water is 1.2 metres)

Do you give permission to Labour Loot Aquanatal® to take photos of you in class and using them for advertising, on social media and on the Labour Loot Aquanatal® website? *

Images would be taken from above water with only your head and upper body visible OR underwater with your head/face not visible

Yes

No

Would you like to be added to Labour Loot Aquanatal's® PARTICIPANT WhatsApp group? *

This group chat is used by Aquanatal participants to share news of their baby's arrival (if they want to) and ask questions (eg does anyone know of a good pregnancy yoga class). Clare uses it to make any class announcements (if urgent/personal, you will be contacted directly by Clare)

Yes

No

Would you like to be added to the Aquanatal's® participant SOCIAL WhatsApp group? *

This group chat is used by Aquanatal participants to organise social catch ups around the Northern Beaches. An 'Aquanatal Mother's Group' - the women catch up for a coffee or a picnic and are building lovely friendships which is so important for mental health in pregnancy and after birth.

Yes

No

How did you hear about Labour Loot Aquanatal® classes?

Internet search

Word of mouth/friend

Hospital

Labour Loot (TENS machine hire & other items)

Northern Beaches Mums Facebook/website

Physio/chiro

Midwife/obstetrician/GP

Birth education classes/doula

Social media

My Kids Market

Repeat participant

Other