Antenatal Registration Form
We have designed a specific women’s health questionnaire which screens you for a variety of common pregnancy 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.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Have you been participating in any exercise whilst pregnant? If so, what kind?
How many weeks pregnant are you?
When is your due date?
Are you under the care of a consultant as well as midwifery ?
Yes
No
Are you expecting twins or triplets?
No
Yes, twins
Yes, triplets
Do you have a cervical stitch in place?
Yes
No
Do you have gestational diabetes?
Yes
No
Do you have placenta praevia?
Yes
No
Do you have a low lying plancenta
Yes
No
Please could you provide details of any previous deliveries
Date of previous delivery?
Method of delivery? (vaginal, c-section, forceps, ventouse)
Were there any complications?
Have you had any other deliveries?
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
Have you experienced any of the following: (Please tick)
Reduced foetal movement?
Bleeding from the vagina?
Severe nausea / vomiting?
Altered sight e.g. flashing lights?
Chills or fever?
High or low blood pressure?
A feeling of pelvic pressure?
Abdominal pain?
Trauma to your abdomen?
Severe headache?
A persistent body itch?
Painful or burning urination?
Severe constipation?
Swelling or puffiness of the face?
Fainting or dizziness?
Lower back pain?
Leg cramps?
None of these symptoms
Consent
Submit
Should be Empty: