Client Questionnaire (pregnancy)
Please read and fill in the form with as much detail as you can, as it will allow me to get a detailed picture of where you are at ahead of our sessions together! Any information provided by you will not be shared with any third parties.
Full name: *
Your answer
Address: *
Your answer
Mobile number: *
Your answer
Email address: *
Your answer
GP name and address: *
Your answer
GP telephone number: *
Your answer
Emergency Contact Name (and relationship to you): *
Your answer
Emergency Contact Mobile Number: *
Your answer
Due Date: *
MM
/
DD
/
YYYY
Is this a single or a multiple pregnancy? *
Do you have other children at home? *
If yes, please list names and ages:
Your answer
Are there any details from previous pregnancies, labours, or recoveries that you feel may be relevant to our training?
Your answer
Details of pregnancy so far (any complications)? *
Your answer
When was your last visit to a Primary Health Provider? What was the outcome? *
Your answer
Do you have a history of extreme high blood pressure – either currently or have a previous history of this? *
If yes, please provide details if possible, including any treatment:
Your answer
Have you any skin rashes, open or unhealed cuts or bruises? *
Have you experienced any rapid or large weight gain while pregnant, or in previous pregnancies?
Are you experiencing any extreme itchiness? *
Do you have a history of miscarriage? *
Are you experiencing any excessive or sudden swelling and water retention? *
Do you have a history of blood clots or Thrombosis? Any extreme calf pain, swelling or redness? *
Are you experiencing excessive thirst and/or urination? *
Are you experiencing varicose veins or haemorrhoids? *
Currently, or in previous pregnancies have you experienced any of the following (tick as many as apply)? *
Required
Are you experiencing difficulty with your bowel, wind or urinary urges? *
Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly? *
Are your bowel movements or urination painful? *
Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Has anyone ever said you may have a prolapse? *
Do you experience pain with intercourse or sexual stimulation? *
Do you currently or have you ever needed to wear incontinence pads? *
Do you experience pain inside or at the joints of your pelvis? *
Do you have a history of low back pain or any other type of back pain? *
Do you suffer from constipation or regularly strain on the toilet? *
Do you or have you ever had a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?) *
Are you or have you been overweight? *
Do you frequently lift heavy weights? (Gym, work, children, caring for older children, disabled persons or elders?) *
On a scale of 1 to 10, how would you rate your sleep? *
Awful
Very good
Please give details of sleep habits (or sleep issues):
Your answer
Describe, as best you can, your typical daily food intake: *
Your answer
Describe, as best you can, your typical daily liquid intake, including tea and/or coffee (and include any alcohol consumed on a weekly basis): *
Your answer
Are you taking any vitamins or supplements? *
If yes, please provide details:
Your answer
Would you be interested in free nutritional support alongside your training? *
Do you or have you ever smoked? *
Are you on any medication? *
If yes, please provide details: *
Your answer
On a scale of 1 to 10, how would you rate your fitness PRIOR to getting pregnant? *
Non-existent!
Very fit
Please provide details of any regular exercise you did before getting pregnant: *
Your answer
Please provide details of any regular exercise you've been doing since finding out you were pregnant; *
Your answer
Have you ever been advised by your doctor that you have a heart condition and should ONLY do physical activity recommended by a doctor? *
Do you ever feel pain in your chest when you do physical activities? *
Have you ever felt chest pain when NOT doing physical activity? *
Do you ever lose consciousness or fall over as a result of dizziness? *
Do you have a bone or joint issue that is aggravated by physical activity? *
If yes, please provide details:
Your answer
Has your doctor ever recommended medication for your blood pressure or heart condition? *
Are you aware, through your own experience or a doctor's advice, of any other physical reason against your exercising without medical supervision? *
If yes, please provide details:
Your answer
How is your health in general, do you need to tell us about any other health issues that you have? *
Your answer
How are you feeling emotionally? Tick all or any that apply: *
Required
List up to five goals that you have in mind for your training with me (this can be a tricky one, but try and think of at least one!): *
Your answer
I have read, understood and completed this questionnaire to the best of my knowledge: *
Please type your name and today's date below (to serve as an electronic signature): *
Your answer
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