Postnatal health screening form
Postnatal health questionnaire please give as much information as you can.
Full Name:
Your answer
Date of Birth:
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DD
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YYYY
Best contact number:
Your answer
Email:
Your answer
Date of Delivery:
MM
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DD
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YYYY
What type of delivery you had:
Did you have an episiotomy?
Have you had your 6 week post natal check up?
What was the outcome of your 6 week post natal check up?
Your answer
Do you currently do any type of exercise? If yes, tell me about that here:
Your answer
General Health Screening Questions
Has a doctor ever diagnosed you with a heart condition?
Your answer
Have you ever been advised that you should only do exercise recommended by your doctor?
Your answer
Do you feel pain in your chest when you do physical activity?
Your answer
In the past month have you experienced chest pain when you are not doing physical activity?
Your answer
Do you ever lose your balance due to dizziness? or lose consciousness?
Your answer
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Your answer
Are you currently being prescribed drugs for your blood pressure or for a heart condition?
Your answer
Are you diabetic?
Your answer
Do you currently suffer from any of the following conditions - please tick all the apply:
Please provide any further information you feel is relevant to the questions above:
Your answer
Do you know of any reason why you should NOT take part in physical activity?
What is your main motivation for doing my class? (e.g. general fitness, core strengthening, posture, help with back pain, social)
Your answer
Please check this box to let me know that you agree to me contacting you by email with details of my classes and services and to notify you of any changes to class times or cancellations.
DATA PROTECTION: Please check this box to confirm that you understand that Kim Jones Wellbeing will hold the personal information you provide here securely and will not share this information with any third parties without your prior consent.
Please let me know if you are happy to receive my newsletter and details of events that I am running by email.
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