Pregnancy Assessment Form

Full Name

First NameLast Name

Date of birth

MonthDayYear

E-mail

Phone

Due Date

Obstetrician or Midwife

Hospital

Obstetric history

Outline if you have experienced any significant events with this pregnancy

Exercise history

What exercise were you participating in before falling pregnant and what have you been partaking in through your pregnancy to this point

Occupation

Outline any muscle or joint issues you are currently experiencing

If no discomfort or pain please record NIL

Pelvic Floor Symptoms

Please tick off any of the above symptoms that you are currently experiencing. Use the text box below to provide details on your symptoms such as severity, aggravating activities, treatment, etc.

Provide further information on your pelvic floor symptoms. Skip if you have no pelvic floor concerns

Tick any medical condition that applies to you

Is this a multiple pregnancy?

Is this your first pregnancy?

If you answered NO in the above question please complete the information below

Number of births

Prior birth history

Please include child AGE, Type of Birth (Vaginal/Caesarian), and any relevant information related to recovery including past abdominal seperation, perineal tearing or pelvic girdle/back pain

Where did you here about these classes?

Goals you hope to achieve through Classes

Please include at least one goal hope to achieve through attending pregnancy classes

Any other information you would like to share

Advice offered (Section for Admin to Complete)