Post-natal exercise screening - for Carly at www.projecthb.co.uk
Please complete all parts of this form and be prepared to provide further details, prior to commencing an exercise programme with me. It will take about 20 minutes and I'll ask some intimate questions about your birthing experience and post-birth body. I really want to support you in your next steps to fitness, so I need to get a good understanding of the sort of pregnancy and birthing journey you have had, and how you're doing right now, so I can tailor your programme to your needs and keep you feeling safe and comfy!

Why am I collecting this data? By completing this form you are agreeing to accept the risks of physical exercise, meaning my professional indemnity and public liability insurance is valid, and I am legally allowed to work with you. I reserve the right to refer you to an alternative specialist or decline to take you on as a client dependent on the answers you give on this form. I will offer full explanations about my decision if this decision is made. The contents of this form, protects us both.

What do I do with your data? I store form securely for 3 years from the day you signed last attended an exercise session with me, upon which point your data will be permanently deleted. If you want me to delete your data before this cut off time, please email me at projecthb@live.co.uk requesting this, and I will delete all data I have stored about you, immediately.

Please note: You may need to complete this form again, if you request I delete your data, and then want to attend another class.
1. Your personal contact details
Full name *
Email address *
Phone number *
How did you hear about MamaFit? *
Emergency contact name & relationship to you *
Emergency contact telephone number *
2. Questions about your most recent pregnancy
Which baby was this for you? *
Was your pregnancy midwife or consultant led? *
Was your most recent pregnancy singular or multiple? *
Was your most recent baby born at 32 weeks (8 months) or earlier? *
During your pregnancy, did a medical professional tell you that you had any of the following conditions? *
Did you experience any of the following, during your pregnancy? *
3. Questions about your labour and birthing experience
What date did you have your most recent baby? *
Have you had your 6-week check-up (for a vaginal birth) or 12 week check up (for a Caesarean/c-section birth), with a medical professional yet? *
Have you been given the all-clear to exercise, following this check-up? *
What type of birth was your most recent birth? *
Did you have an episiotomy (surgical cut to enlarge the baby's delivery channel)
How would you describe your birthing experience (you can select more than one)? *
Required
Is there anything else you want to let me know about your birthing experience? *
4. Questions about your 4th trimester & beyond (you and your body)
How many hours of sleep (roughly) are you getting in a 24 hour period? *
Have your menstrual cycle (your periods) returned to a cycle which is normal for you, since the birth of your most recent baby? *
If you had a vaginal birth, did you experience any tearing? *
If you had a vaginal birth and experienced tearing please elaborate so I can best look after your physical health needs in class (you can select more than one option)? *
Required
Have you experienced a post-birth prolapse (collapsing of womb, bowel or bladder against the vaginal wall and a "bulging" uncomfortable feeling)? *
If you had a Caesarean/C-section birth how is your wound healing? (you can check more than one option)? *
Required
Did you experience a separation of the abdominal wall (down the middle of your tummy, anywhere from your rib cage to your belly button) while pregnant, which is still present now? *
What sort of exercise are you doing at the moment? (You can choose more than one - and if you're not doing anything at the moment, absolutely no probs!) *
Required
Do you experience any incontinence (urine leaking or bowel weakness) when you laugh, jump, run, sneeze or shout? You can answer more than one option. (This is totally normal and experienced by MANY women). *
Required
How are you feeding your baby at the moment? *
Is there anything else you want to let me know about how you're feeling about your body? *
5. Questions about your general physical health
Please tick 'yes' or 'no' for all of the following *
Yes
No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Is there anything else you'd like to disclose about your health? *
GIVING CONSENT TO PARTICIPATE: Please read the following statement and type your name at the beneath, if you agree.
**Please type your name below** Subject to further conversation and prior to beginning an exercise programme with Carly Wilkinson, I, the undersigned understand the exercise session that I will perform and the associated risks and discomforts. Knowing these risks and discomforts, having understand and accept that I am free to cease exercising at any point during the session and that I have the opportunity to ask questions throughout. I consent to participate in this exercise session. *
Date signed *
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