HEALTH SCREENING FORM

Client NameDate of delivery
Baby's NameType of delivery
Client Address6 week check-up date
6 week check-up outcome
Breastfeeding status
Postcode Post natal bleeding status
Client EmailRecently fitted Intra Uterine Device (IUD)
Client Phone 
Please give details of your Pregnancy & Post Natal, include any complications, illnesses, reasons to visit your Doctor or any other Health Practitioner including Massage, Acupuncture, Pilates, Physiotherapy, Osteopathy, Chiropractor etc.
Do you currently or have you ever suffered any of the following conditions? Please tick if YES.
Symphysis Pubis Dysfunction
(pain in the central pubic area)		 Sacrum or Sacroiliac Joint Pain
(pain in the very low mid back – top of buttocks)		 Bleeding during or after exercise or any unexplained bleeding
Carpal Tunnel Syndrome
(Wrist/finger/hand forearm -pain/numbness or tingling)		 Knee Pain
(Side, front or back)		 High/lowblood pressure, episodes of faintness, dizziness or breathlessness
Upper Back/Neck/Shoulder Pain Coccyx Damage or Pain Separation of your abdominal muscles
Incontinence
(Urinary or Faecal)		 Prolapse
(Uterine, Bladder, Rectum, Vaginal)		 Breast Health/Breast Feeding Issues/Mastitis
Piles/Haemorrhoids/Varicose Veins/Constipation Were you given an Epidural during birthing? Nerve Damage During Birthing
(Pudendal)
Gestational Diabetes C-Section wound discomfort or slow healing or ongoing numbness Anaemia or taking Iron medication
Joint Pain / Muscle Pain Buttock/Piriformis Pain/Sciatica Episiotomy Cut, Painful Perineum or Tears
(Degree if known)

Readiness & Lifestyle QUestions
1. Please detail any relevant/important information relating to previous Pregnancies and Post Birth periods, such as periods of illness or negative outcomes.
2. Are you taking any medication? Give details:
3. What are your goals or reasons for participating in exercise?
4. Can you briefly detail your previous and current exercise abilities/activities?
5. Is there anything in your medical history you feel could affect your ability to exercise?
6. Are you getting up at night? How much sleep are you getting?

Confirmation

I can confirm that I have had the all clear by my GP to commence suitable postnatal exercise. I am aware that I must feel well prior to each class and will notify you (the trainer) should I feel unwell at any time during the class.

Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for postnatal women. I understand that my participation and the safety of both my child/children and myself are my responsibility.

Newsletter Consent

If you would like to receive my Newsletter, with useful post-natal, nutrition and exercise tips then please click either Yes or No to give your consent.
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