Postnatal Screening Questionnaire

Postnatal Screening Questionnaire
All responses will be treated in strict confidence, held securely (password protected) and will be destroyed after 6 months.
Full Name

First NameLast Name
Mobile Number

Area CodePhone Number
Date of Birth

DayMonthYear
Date
Email
example@example.com
Date of Delivery:
Type of delivery
Did you have an episiotomy or perineal tear?

YesNo
Have you had your 6-8 postnatal check-up? If so, what was the outcome?
Are you currently doing any type of exercise? If so, what and how often?
Any previous pregnancies? Previous births? Please include any details on complications, issues experienced, type of births etc.
Health/ Postnatal Screening Questions
Has your doctor ever said that you have a heart condition AND that you should only do exercise recommended by your doctor?

YesNo
Do you feel pain in your chest when you do physical activity?

YesNo
In the past month, have you had chest pain when you are not doing physical activity?

YesNo
Do you lose your balance because of dizziness or do you ever lose consciousness?

YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity

YesNo
Is your doctor currently prescribing drugs for your blood pressure or heart condition?

YesNo
Are you diabetic?

YesNo
Are you currently suffering from any of the following conditions? Please select if YES

Symphysis Pubis Dysfunction (pain in the central pubic area)Carpal Tunnel Syndrome (wrist/finger/hand/ forearm - pain/numbness or tingling)Upper back/ Neck/ Shoulder painLack of total bladder/bowel control (urinary or faecal incontinence)Loss of urinary control when laughing, sneezing, coughing, jumping or moving quicklyNeed to wear incontinence padsPiles/Haemorrhoids/Varicose Ceins/ ConstipationAfter Effects of Gestational DiabetesSacrum or Sacroiliac Joint Pain (pain in the very low mid-back - top of buttocks)Knee pain (side/front)Coccyx damage or pain (tail bone)Feeling of heaviness in pelvis or prolapse (uterine, bladder, rectum, vaginal)Were you given an epidural during birthing?C-section wound discomfort or slow healing or ongoing numbness?Buttock/piriformis pain/ sciatica/ pain inside or around joints of pelvisBleeding during or after exercise or any unexplained bleedingHigh/low blood pressure, episodes of faintness, dizziness or breathlessness, history of thrombosis or blood clotsPossible Diastasis Recti (separation of 6-pack muscles)Breast health/ breast feeding issuesNerve damage during birthing (especially pudendal)Anaemia or taking iron medicationEpisiotomy cut, painful perineum or tearsDifficulty with your bowel, wind or urinary urgesPainful bowel movements or urinationConstipation or straining on the toiletChronic cough or condition that effects your breathing
Provide any further information here that you feel necessary in relation to the above questions.
Is there anything about your pregnancy, birth or current wellbeing you feel is relevant to your participation in exercise or receiving a massage therapy treatment?
Do you know of any other reason why you should not do physical activity?

YesNo
What are your short or long term goals for participating in exercise and/or receiving massage therapy treatments? What part of your physical or mental wellbeing are you most motivated at improving right now?
How would you describe your current diet? Include any regular cravings you have.
Are you breastfeeding?

YesNo
Which services at Willow are you interested in finding out more about?

Online group exercise classesStudio group exercise classes121 exercise sessionsNutritionMassage/soft tissue therapyGroup educational workshopsPostnatal health checkC-Section scar tissue therapyReturn to running
STAYING IN CONTACT: I understand and agree that Michelle Brown may contact me by email to send reminders of classes or for other general messages pertaining to Michelle Brown Women's Wellness.

I agree
DATA PROTECTION: I understand that Michelle Brown will hold my personal information (including responses on health questionnaire) securely (password protected) and will not share this with any third parties without my prior consent. If at any time I do not wish my details to be held and no longer wish to use Willow services, I can requested for my personal information to be carefully destroyed. I also understand that by registering for Michelle Brown Women's Wellness services, my name and email will be added to an email mailing list where occasional emails will be sent relating to services, news, offers and relevant blog articles. My email will not be shared with any third parties and I can unsubscribe from this mailing list at anytime.

I agree
Therapist Notes
Should be Empty: