Lindsay Clarke

Active Birth Class Personal Registration

This form is to be completed and sent together with the booking form and
payment. The details on this form will be kept confidential. Please leave
blank any questions you do not wish to answer.

Name ___________________________ Date of Birth __________________________

Address ________________________________________________________________

_________________________________ Post Code ____________________________

Email address ___________________________________________________________

Telephone __________________________ Mobile ____________________________

Due Date ___________ How did you hear about classes _______________________

Occupation _____________________________________________________________

Where are you having your baby? ___________________________________________

Are you happy with this choice? ____________________________________________

Who else will be at the birth? ______________________________________________

Have you had: Scan? ___________________ Amniocentesis? __________________

Any other special tests? __________________________________________________

Have you had any relevant accidents or injuries? _____________________________

Are you on any medication? _______________________________________________

Any other medical problems? _______________________________________________

Heartburn? __________ Piles? ___________ Backache? _______________________

Previous pregnancies: Miscarriages? ________________________________________

Other children (age, place of birth) _________________________________________

I agree for my own safety, to inform my teacher at the beginning of
any class should there be any change in the above information.
Signed ______________________________________ Date ______________________