Pregnancy & Post-natal Health Questionnaire

Name*

First NameLast Name

Phone Number*

Email*

Address*

CityCounty

Post Code

Date of Birth*

Emergency Contact name*

First NameLast Name

Emergency Contact's Phone number*

Baby's Name

First NameLast Name

Baby's Date of Birth

What is the Due date of your current pregnancy?

Which Trimester are you currently in?

First Trimester (0-12 weeks)Second Trimester (13-26 weeks)Third Trimester (27-40 weeks)

Did you conceive naturally or by IVF?

NaturallyIVF

If via IVF, how many treatments did you have?

Do you have any particular worries or concerns about exercise during pregnancy?

Have you chosen a particular birthing plan? If so, please give BRIEF details here:

If you have children, please give their names and D.O.B here:

Child #2

Child #3

Child #4

Please indicate the methods of delivery for these children by writing the number indicated in previous question alongside the relevant method for that child.

Vaginal delivery (no intervention)

E.g. 2 & 3

Vaginal delivery with medical intervention (e.g. Forceps)

Caesarean Section

Did you have any problems during your previous pregnancies, births or postnatal period?

Is your blood pressure*

NormalLowHigh

If you selected high in the last question, is it being medically controlled?

YesNo

Have you ever experienced any of the following, past or present? Please select all that apply.*

Have you ever suffered with Pelvic Girdle Pain? E.g. symphysis pubis dysfunction, sacroiliac joint pain? If yes please give brief details of condition and treatment (e.g. Physiotherapy).*

Do you lose your balance because of dizziness or do you ever lose conciousness, feel faint or dizzy?*

YesNo

Have you had major surgery in the last 10 years (except C-Section)?*

YesNo

If yes, please give details

Have you had minor surgery in the last two years?*

YesNo

If yes, please give details

Have you ever been told that you have arthritic joints, osteoporosis or any bone or joint problem that may affect your ability to exercise?*

YesNo

If yes, please give details

Do you have neck or back pain?*

YesNo

If yes, please give details

Do you have pain or restricted movement in any other joints? (E.g. hip, knee, ankle, shoulder?*

YesNo

If yes, please give details

Are there any movements or positions which cause you pain?*

YesNo

If yes, please give details

Is there anything else in your medical history that you feel could affect your ability to exercise?*

YesNo

If yes, please give details

Are you taking any medications that may affect your ability to exercise?*

YesNo

If yes, please give details

Are you currently seeing a Physio/Osteo/Chiropractor or similar therapist?*

YesNo

If yes, do you give permission for us to contact them ?(please give name and contact number if so)

First NameLast Name

Phone number

It is important that you advise us before commencing any session if, for any reason, your health or ability to exercise changes.

Pilates is a very safe form of exercise, however, as with all forms of exercise, it is prudent to consult your doctor if you suffer from any health problems or special conditions, or if you are in any doubt as to its suitability. If you are undergoing any medical treatment or are taking medication, you will need to consult your medical practitioner first. Pilates should not be considered a replacement for professional medical counselling or treatment. We strongly recommend that you check with your midwife or doctor that it is still appropriate to exercise as you progress through your pregnancy (perhaps at your regular antenatal sessions).

Exercise should be performed at a pace which feels comfortable for you. PAIN is the body's warning system and should NOT BE IGNORED. You must take responsibility for your own body during each Pilates session and must inform your instructor if you feel any discomfort. Please also inform the instructor if you felt any discomfort after a previous session.

The Pilates Corner and Pilates with Emma nor the instructor accept no liability related to participation in the class if:

The Doctor has advised you against such exercise.
You do not act responsibly with your body or fail to observe instruction on safety or technique.
Such injury is caused by the negligence of another participant in the session/studio.

I understand that Pilates exercises involve hands-on correction and I hereby consent for my instructor to work in this way. I understand that I will be charged for my class if I do not give 12 hours notice or cancellation (24 hours' notice for 1:1 sessions).

I confirm that I have read and understood the above advice and that the information I have given here is correct.

Signed

Date

How did you hear about The Pilates Corner?*

Name of friend that referred you so we can thank them

First NameLast Name

If you had a flyer, please let us know where the flyer came from

I'm happy to receive information and offers from The Pilates Corner and Pilates with Emma*

Yes, I'm happy to be contactedText onlyEmail onlyNo contact

Pregnancy & Post-natal Exercise Questionnaire

Your Background & Your Health

Section 1 - Current Pregnancy

Please now go to section 3 (unless you have had any other babies in the last 12 months, then please also complete section 2).

Section 2 - Past Pregnancies

Section 3 - to be completed by all