Postnatal Screening Form

Postnatal Screening Form

All information will be kept private and confidential
Full Name*

First NameLast Name
Email*
example@example.com
Date of birth

DayMonthYear
Date
Phone Number*

Area CodePhone Number
Emergency contact *

First NameLast Name
Emergency contact phone number*

Area CodePhone Number
How did you hear about the class?
Which class/classes are you interested in?
How many children do you have?*
Child 1 - name
Child 1 - D.O.B.

MonthDayYear
Date
Child 1 - Type of delivery
Child 2 - name
Child 2 - D.O.B.

MonthDayYear
Date
Child 2 - Type of delivery
Child 3 - name
Child 3 - D.O.B.

MonthDayYear
Date
Child 3 - Type of delivery
What are your goals for participating in exercise?
Has your Doctor completed your 6-8 week postnatal check*

YesNo
Did you exercise during your pregnancy?*

YesNo
Did you have an episiotomy?*

YesNo
Did you have stitches?*

YesNo
Has your bleeding stopped?*

YesNo
Are you breast-feeding?*

YesNo
Did/Do you suffer from Pelvic Girdle Pain?*

YesNo
Has your GP completed your REC Check*

YesNo
Have you experienced any of the following in the past or present:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyBronchitisPneumoniaThyroid IssuesHerniaMigraine/HeadachesHigh blood pressureLow blood pressureWrist pain-Carpel Tunnel SyndromeAbdominal crampsPelvis / Pubic painProlapse / weak Pelvic FloorJoint problem –neck / back / shoulder / knee / hip / ankleArthritisStrokeHeart attackOther
Check any symptoms that you're currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
Please give details of any of the above conditions or symptoms, if applicable
Are you currently taking any medication that your instructor should be aware of?*

YesNo
Are you PREGNANT or had a baby within the last 6 months?*

YesNo
Is there any reason why you should not participate in physical activity?*

YesNo
Please give any other information you feel is relevant
By sumitting this form, I hereby confirm that all the above information is correct and accurate at the time of activity.

I know of no reason why I should not participate in an exercise programme. I have been cleared by a doctor for physical activity. I agree to advise in writing if any changes to my health should affect my participation.

I take part at my own risk and I waive any legal recourse for damages to myself, my child or property arising from participation.
Date

DayMonthYear
Date
Signature*

Clear
Should be Empty: