Pregnancy Screening Questionnaire

Pregnancy 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
Your Due Date/Number of Weeks Pregnant:
How physically active were you in the 6 months before pregnancy?
What exercise are you currently doing during this pregnancy?
Do you have any physical activity goals for the rest of this pregnancy?
Any previous pregnancies? Previous births? Please include any details on complications, issues experienced, type of births etc.
Health/ Pregnancy 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
Please select any of the following conditions if you are experiencing them.

Significant heart or cardiovascular diseaseSignificant lung or respiratory diseaseIncompetent cervixMultiple gestation at risk of premature labourPersistent spotting/bleeding or Placenta PreviaPremature labourRuptured membranesUncontrolled Type 1 Diabetes or Gestational DiabetesEvidence of Intrauterine Growth RestrictionPregnancy-induced Hypertension or Pre-EclampsiaUncontrolled epileptic fits/seizuresThree or more previous miscarriagesLoss of urinary control when laughing, sneezing, coughing, jumping or moving quicklyAnaemia or taking iron tabletsUnstable thyroid disease
Provide any further information here that you feel necessary in relation to the above questions.
Have you ever experienced any of the conditions listed below whilst exercising during your current pregnancy?

Vaginal spottingDyspoena (difficult or laboured breathing) before exertionDizzinessHeadacheChest PainCalf pain or swellingPrevious preterm labourPrevious decreased foetal movementSuspected amniotic fluid leakageDramatic weight gain or lossSwelling or general noticeable appearance of puffinessItchinessNoticeable increase in thirst
Provide any further information here that you feel necessary in relation to the above questions.
Currently, or during previous pregnancies have you suffered any of the following conditions?

Pelvic Girdle PainCarpal Tunnel SyndromeUpper Back PainSeparation of your abdominal muscles (Diastasis Recti)Sacrum or Sacroiliac Joint Pain (lower back/upper buttocks)Knee PainVaricose VeinsNeck PainLower Back PainBleeding during pregnancyCoccyx (tail bone) damageGestational Diabetes
Do you know of any other reason why you should not do physical activity?

YesNo
What are your goals for participating in exercise and/or receiving a massage therapy treatment? 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.
Which services at Michelle Brown Women's Wellness are you interested in finding out more about?

Online group exercise classesIn-person group exercise classes121 exercise sessionsNutritionMassage/Soft Tissue TherapyGroup educational workshopsPostnatal health check
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 Michelle Brown’s services, I can request 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: