Postnatal Client Questionnaire
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
Telephone number: *
Your answer
Email address: *
Your answer
GP name and address: *
Your answer
GP telephone number: *
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Telephone Number: *
Your answer
Baby's name: *
Your answer
Baby's Date of Birth: *
MM
/
DD
/
YYYY
Baby's Birth Weight: *
Your answer
What type of delivery did you have? *
If you had a vaginal birth, did you suffer any tearing or undergo an episiotomy? *
Was your labour induced? *
Did you have an epidural during your delivery? *
Do you currently have, or have you ever suffered from any of the following: (tick as many as apply) *
Required
Please provide details: *
Your answer
Did you attend a 6/8 week check up with your GP? *
If so has your GP specifically 'cleared' you for exercise? *
Other than your new baby, do you have other children at home? *
If yes, please list their ages: *
Your answer
Are you: *
Do you have any of the following to help with the baby? Tick any/all that apply:
How are you feeding your baby? *
On a scale of 1 to 10, how would you rate your sleep? *
Awful
Brilliant
Please provide details if you can (i.e. is baby sleeping through the night, do you manage to nap during the day)
Your answer
Describe, as best you can, your typical daily food intake: *
Your answer
Are you taking any vitamins or supplements? *
If yes, please provide details: *
Your answer
Are you still experiencing postnatal bleeding? *
Have you had a recently fitted IUD? *
Please provide details of your pregnancy (any complications, illnesses, visits to GP or other healthcare practitioners such as chiropractor, acupuncturist, physio, osteopath) *
Your answer
Please provide details of your postnatal recovery so far (any complications, illnesses, visits to GP or other healthcare practitioners such as chiropractor, acupuncturist, physio, osteopath) *
Your answer
Are you experiencing difficulty with your bowel, wind or urinary urges? *
Do you ever lose urinary control when laughing, sneezing, coughing, jumping or moving quickly? *
Are you incontinent overnight?
Do you currently or have you ever needed to wear incontinence pads? *
Are your bowel movements or urination painful? *
Do you suffer from constipation? *
Do you ever experience a sensation of pressure in your vagina or rectum (like a tampon falling out) or noticed any protrusions from either? Or has anyone ever said you may have a prolapse? *
Do you experience pain inside or at the joints of your pelvis/hips? *
Have you ever undergone any gynaecological surgery (e.g. fibroids removal)? *
If yes, please provide details: *
Your answer
Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx)? *
If yes, please provide details: *
Your answer
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 good
Please provide details of any regular exercise you did before getting pregnant: *
Your answer
On a scale of 1 to 10, how would you rate your fitness DURING your pregnancy? *
Non-existent
Very good - I stayed very active
Please provide details of any regular exercise you did during your pregnancy: *
Your answer
On a scale of 1 to 10, how would you rate your fitness since giving birth? *
Non-existent
Very good - I've been very active since giving birth
Please provide details of any regular exercise you've been doing since giving birth: *
Your answer
Have you been given any specific exercises to do by a healthcare provider (e.g. physio)? *
If yes, please provide details: *
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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