ForbesPilates :: Pre & Post Natal form

Have you experienced any of the following, past or present? Please tick all that apply.

shortness of breath

chest pain

miscarriage

eating disorder

seizures

vaginal disorder

blood disorder

major surgery in the last 10 years

minor surgery in the last 10 years

heart disease

hypoglycaemia

pelvic/abdominal cramps

vaginal bleeding

incompetent cervix

multiple gestation (twins etc)

diabetes

multiple births

high blood pressure

low blood pressure

knee problems or pain

back problems or pain

neck problems or pain

osteoporosis

arthritis

bone/joint pain

other condition effecting movement

What type of exercise did you participate in before your pregnancy? *

Is there anything in your medical history that you feel could affect your ability to exercise? *

Are you taking any medications that may affect your ability to exercise? *

Did you have any problems during previous pregnancies, births, or in the postnatal period that may impact your ability to exercise? *

Is there anything about your pregnancy or birth you feel relevant to your participation in an exercise program? *

What concerns you most about pregnancy, birth, or the postnatal period? *

What are your goals in a Pilates class? *

FOR PRENATAL ONLY: Due date *

FOR PRENATAL ONLY: what trimester are you currently in *

Has your doctor or midwife given you medical clearance to take part in exercise? *

FOR POSTNATAL ONLY: Date baby was born

FOR POSTNATAL ONLY: Type of delivery

FOR POSTNATAL ONLY: Did you have an Episiotomy?

FOR POSTNATAL ONLY: Are you breast feeding?

FOR POSTNATAL ONLY: Are you getting up at night?

FOR POSTNATAL ONLY: Are you napping during the day?

I have read, understood, and completed the questionnaire *

Your Name *

Date today *

mobile phone *

Address *

Postcode *

email *

Occupation *

Hobbies and regular activities *

Your date of birth *

Emergency contact name *

Emergency phone *

Emergency 2nd contact name

Emergency 2nd named person phone number

Doctors name

Doctors phone number

Midwife name

Midwife contact number

Hospital

Do you give us permission to contact your doctor/medical practitioner? If you wish contact provide details

Are you comfortable walking up and down stairs? Otago street Pilates studio is on the 4th floor. Please be aware of this if you are attending this Pilates Studio. *

Have you experienced any of the following, past or present? Please tick all that apply.	shortness of breath chest pain miscarriage eating disorder seizures vaginal disorder blood disorder major surgery in the last 10 years minor surgery in the last 10 years heart disease hypoglycaemia pelvic/abdominal cramps vaginal bleeding incompetent cervix multiple gestation (twins etc) diabetes multiple births high blood pressure low blood pressure knee problems or pain back problems or pain neck problems or pain osteoporosis arthritis bone/joint pain other condition effecting movement
What type of exercise did you participate in before your pregnancy? *
Is there anything in your medical history that you feel could affect your ability to exercise? *
Are you taking any medications that may affect your ability to exercise? *
Did you have any problems during previous pregnancies, births, or in the postnatal period that may impact your ability to exercise? *
Is there anything about your pregnancy or birth you feel relevant to your participation in an exercise program? *
What concerns you most about pregnancy, birth, or the postnatal period? *
What are your goals in a Pilates class? *
FOR PRENATAL ONLY: Due date *
FOR PRENATAL ONLY: what trimester are you currently in *
Has your doctor or midwife given you medical clearance to take part in exercise? *
FOR POSTNATAL ONLY: Date baby was born
FOR POSTNATAL ONLY: Type of delivery
FOR POSTNATAL ONLY: Did you have an Episiotomy?
FOR POSTNATAL ONLY: Are you breast feeding?
FOR POSTNATAL ONLY: Are you getting up at night?
FOR POSTNATAL ONLY: Are you napping during the day?
I have read, understood, and completed the questionnaire *
Your Name *
Date today *
mobile phone *
Address *
Postcode *
email *
Occupation *
Hobbies and regular activities *
Your date of birth *
Emergency contact name *
Emergency phone *
Emergency 2nd contact name
Emergency 2nd named person phone number
Doctors name
Doctors phone number
Midwife name
Midwife contact number
Hospital
Do you give us permission to contact your doctor/medical practitioner? If you wish contact provide details
Are you comfortable walking up and down stairs? Otago street Pilates studio is on the 4th floor. Please be aware of this if you are attending this Pilates Studio. *