Post-Natal Registration Form
We have designed a specific women’s health questionnaire which screens you for a variety of common post-natal conditions. You may find some of the questions quite detailed but this is so that we can ensure we don't miss anything and can let you know whether we need to refer you to a pelvic health physio prior to stating pilates with us. If you are unsure about any of these questions, or would prefer to speak to someone directly, please contact us.
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Did you participate in exercise while pregnant?
Yes
No
Have you had your 6 week check? Were there any complications?
Are you still under the care of a consultant and if so why?
Have you had an internal examination?
Yes
No
Are you breastfeeding?
Yes
No
Are you still bleeding?
Yes
No
Do you ever experience urine and/or stool leakage?
Yes
No
Do you experience a sensation of pressure or heaviness in your vagina or rectum or ever noticed a bulge inside?
Yes
No
Do you experience pain in your vulva or vagina with or without sex?
Yes
No
Please give details of your delivery or any previous deliveries
Date of most recent delivery?
Method of delivery? (vaginal, c-section, forceps, ventouse)
Were there any complications?
Have you had any previous deliveries?
Consent
I am not a robot
*
Submit
Should be Empty: