Willow Studio Pregnancy Screening Questionnaire

Willow Studio 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 Name Last Name
Mobile Number

Area Code Phone Number
Date of Birth

Day Month Year
Date Date Picker Icon
Email
example@example.com
Your Due Date/Number of Weeks Pregnant:
What exercise are you currently doing?
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?

Yes No
Do you feel pain in your chest when you do physical activity?

Yes No
In the past month, have you had chest pain when you are not doing physical activity?

Yes No
Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No
Do you have a bone or joint problem that could be made worse by a change in your physical activity

Yes No
Is your doctor currently prescribing drugs for your blood pressure or heart condition?

Yes No
Are you diabetic?

Yes No
Please select any of the following conditions if you are experiencing them.

Significant heart disease Significant lung disease Incompetent cervix Multiple gestation at risk of premature labour Persistent spotting/bleeding or Placenta Previa Premature labour Ruptured membranes Uncontrolled Type 1 Diabetes or Gestational Diabetes Evidence of Intrauterine Growth Restriction Pregnancy-induced Hypertension or Pre-Eclampsia Uncontrolled epileptic fits/seizures Three or more previous miscarriages Loss of urinary control when laughing, sneezing, coughing, jumping or moving quickly Anaemia or taking iron tablets
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 spotting Dyspoena (difficult or laboured breathing) before exertion Dizziness Headache Chest Pain Calf pain or swelling Previous preterm labour Previous decreased foetal movement Suspected amniotic fluid leakage Dramatic weight gain or loss Swelling or general noticeable appearance of puffiness Itchiness Noticeable 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?

Symphysis Pubis Dysfunction (SPD) Carpal Tunnel Syndrome Upper Back Pain Separation of your abdominal muscles (Diastasis Recti) Sacrum or Sacroiliac Joint Pain (lower back/upper buttocks) Knee Pain Varicose Veins Neck Pain Lower Back Pain Bleeding during pregnancy Coccyx (tail bone) damage Gestational Diabetes
Do you know of any other reason why you should not do physical activity?

Yes No
What are your goals for participating in exercise?
STAYING IN CONTACT: I understand and agree that Michelle Bailey of Willow Studio may contact me by email to send reminders of classes or for other general messages pertaining to Willow services.

I agree
CANCELLATIONS: I understand that quite often there is a waiting list, so my place in my chosen Willow class will be cancelled if I don't attend for three consecutive weeks (unless prior notice given to Michelle).

I agree
DATA PROTECTION: I understand that Michelle Bailey of Willow Studio 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 Willow Studio 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
Should be Empty: