Postnatal health screening form
Postnatal health questionnaire please give as much information as you can.
Date of Birth:
Best contact number:
Date of Delivery:
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?
Do you currently do any type of exercise? If yes, tell me about that here:
General Health Screening Questions
Has a doctor ever diagnosed you with a heart condition?
Have you ever been advised that you should only do exercise recommended by your doctor?
Do you feel pain in your chest when you do physical activity?
In the past month have you experienced chest pain when you are not doing physical activity?
Do you ever lose your balance due to dizziness? or lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Are you currently being prescribed drugs for your blood pressure or for a heart condition?
Are you diabetic?
Do you currently suffer from any of the following conditions - please tick all the apply:
Symphysis Pubis Dysfunction (pain in the central pubic area)
Carpal Tunnel Syndrome (wrist/finger/hand/ forearm - pain/numbness or tingling)
Upper back/ Neck/ Shoulder pain
Lack of total bladder/bowel control (urinary or faecal incontinence)
Loss of urinary control when laughing, sneezing, coughing, jumping or moving quickly
Need to wear incontinence pads
Haemorrhoids/Varicose Veins/ Constipation
After Effects of Gestational Diabetes
Sacrum or Sacroiliac Joint Pain (pain in the very low mid-back - top of buttocks)
Knee pain (side/front)
Coccyx damage or pain
Feeling of heaviness in pelvis or prolapse (uterine, bladder, rectum, vaginal)
Were you given an epidural during birthing?
C-Section discomfort, slow healing or on-going numbness
Buttock/piriformis pain/sciatica/pain inside or around joints of pelvis
Bleeding during or after exercise or any unexplained bleeding
High/low blood pressure
Episodes of faintness, dizziness or breathlessness
History of thrombosis or blood clots
Diastasis (separation of abdominal muscles)
Beast health/breast feeding issues
Nerve damage during birthing
Episiotomy cut/painful perineum
Difficulty with bowel, wind or urinary urges
Painful bowel movements or urination
Chronic coughing or any condition that affects your breathing
Please provide any further information you feel is relevant to the questions above:
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)
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