Postpartum Pre-Exercise Screening Form

Postpartum Pre-Exercise Screening Form

This screening tool helps to assess your readiness and gather necessary health information before starting exercise.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Type of Delivery

Other
Did you experience any complications during pregnancy or delivery?
If yes, please describe the complications.
Have you had your postpartum check-up and been cleared by your healthcare provider to begin or resume exercise?
Are you seeing a pelvic floor physiotherapist?
Are you currently experiencing any of the following?
Do you have any current or past medical conditions we should be aware of?
What are your main goals for returning to exercise?
Do you have any questions or concerns about starting or resuming exercise?
Your child's name and their age
I believe to the best of my knowledge, all the above information I have supplied within this screening tool is correct.
Signature
Should be Empty: