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

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?

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

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

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

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

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

Are you diabetic?

Please select any of the following conditions if you are experiencing them.

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?

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?

Do you know of any other reason why you should not do physical activity?

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?

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.

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.

Therapist Notes