Pregnancy Assessment Form

Postnatal Assessment Form
1. Full Name*

First NameLast Name
2. Date of birth*

MonthDayYear
3. E-mail*
4. Phone*
5. Baby's Name*
6. Baby's Date of Birth*
7. Birth Weight*
8. Obstetrician
9. Hospital*
10. Type of birth*

VaginalCaesarean
If you had a vaginal birth please complete questions 11 and 12. If you had a casearean go to question 13.
11. Mark the appropriate box

Forceps usedVaccuum usedNo instruments required in birth
12. Mark the appropriate box

First or second degree tearThird degree tearForth degree tearEpisiotomyNo tearing
13. Type of Caesarean

ElectiveEmergency
14. Brief summary of birth (If vaginal birth include length of pushing phase if known)*
include any birth complications or during your hospital stay
15. Is this your first birth*

YESNO
If you answered YES go to quesiton 17. If you answered NO please complete question 16.
16. Obstetric History
Record child's name, age, birth weight, type of birth, complications such as abdominal separation or significant perineal tearing
17. Did you exercise regularly prior to this pregnancy*

YESNO
If you answered YES please complete question 18
18. Outline Exercise program prior to pregnancy (include exercise type and frequency)*
19. Did you exercise during your pregnancy*

YESNO
20. Outline Exercise Program during pregnancy or complications that prevented you from exercising
21. Have you returned to any exercise since giving birth*

YESNO
If you answered YES proceed to question 22. If you answered NO go to question 23.
22. Outline the type of exercise and frequency
23. Outline any muscle or joint pain you experienced during pregnancy*
Include when it started, severity and whether you had any treatment. If no discomforts please record NIL
24. Outline any muscle or joint issues you are currently experiencing*
Include when it started, severity and whether you had any treatment. If no discomfort or pain please record NIL
25. Pelvic Floor Symptoms (are you currently experiencing any of these)*

bladder leakageurgency to empty your bladderfeeling of heaviness or dragging vaginallyPain during intercourse or attempting intercourseconstipationurgency to empty bowelsfaecal soilingNone of the aboveOther
If you experience any of the symptoms listed go to question 26. If you have no pelvic floor symptoms proceed to question 27.
26. Please outline the details of the symptoms you are experiencing and any treatment you have received
include when you first noticed them, severity and any treatment you have had
27. Did a Physiotherapist visit you during your hospital stay*

YESNO
28. Are you aware of whether you have an abdominal muscle separation (diastasis)*

YESNOUnsure
If you answered YES complete question 29, otherwise continue to question 30.
29. Approx how large was your separation immediately after birth and now if known
30. Occupation
31. Approx return to work time (if applicable)
32. Where did you here about these classes?*
33.Short term goals (next 3-6mths) Please list 1 - 2 *
Please include at least one goal hope to achieve through attending pregnancy classes
34. Long term goals (next 6-12mths) Please list 1 - 2
35. Are you following the recommended child immunisation program*

YESNO
36. Is there any other information you would like to share before starting classes
Advice offered
Should be Empty:

Postnatal Assessment Form