Kindly fill in the below form. PREGNANCY 1:1 / CLASS Name * First Name Last Name Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date Of Birth MM DD YYYY Due Date MM DD YYYY No. Of Weeks Pregnant Is this your 1st, 2nd, 3rd baby? GP Practice Occupation Emergency Contact Name & Contact Number Please list any previous pregnancies. How are you feeling about your pregnancy? Your experience if you have given birth before (when, where, how you felt, any complications etc). Have you attended any birth prep classes? Any current health issues? How would you describe your general health? Any past injuries? (Neck, back, joints, pelvis) What are your reasons for attending pregnancy classes. Are there any aspects of pregnancy, birth, and/or motherhood you'd like to know more about or have concerns about? How dd you hear about us? I agree to inform the teacher at the beginning of class should any changes appear in the above information, or if any medical, physical, or emotional changes arise while attending the classes. * Thank you!