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GET ACTIVE QUESTIONNAIRE FOR PREGNANCY
Physical activity during pregnancy has many health benefits and is generally not risky for you and your baby. But for some conditions, physical activity is not recommended. This questionnaire is to help decide whether you should speak to your Obstetric Health Care Provider (e.g., your physician or midwife) before you begin or continue to be physically active.
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NAME (+ NAME OF PARENT/GUARDIAN IF APPLICABLE) [PLEASE PRINT]: *
Today's Date *
MM
/
DD
/
YYYY
Due Date *
MM
/
DD
/
YYYY
Number of Weeks Pregnant *
Age *
Phone Number (Optional)
Email Address (Optional)
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