Postnatal Client Health Questionnaire

Postnatal Pilates- Health Questionnaire

Please Read and complete the following questions as fully as you can. The information you share will allow me to tailor your class experience to your specific needs. All details given on this form will be kept in the strictest confidence. Please keep me updated and advise me immediately if any of the given information changes. Thank you.
Full Name *
Date of Birth *

Day Month Year
Phone Number

Area Code Phone Number
E-mail Address *
Emergency Contact (Name/Telephone) *
Name and Date of Birth of your child *
First baby?

Yes Second Third
Medical Information
Has you doctor given you permission to exercise? *

Yes No
Have you had your six-week check by your doctor? *

Yes No
Did your doctor check your abdominals? If yes, any known separation?

Yes, no separation Yes, some separation No Not sure
What type of delivery did you have? *

Vaginal Forceps Ventouse Caesarean Emergency Caesarean
Did you have an episiotomy or tear?
Are you currently under the care of

your midwife a physiotherapist an osteopath a women's health phsyio
Have you experience any of the following?

Pelvic Floor weakness Prolonged second Stage Antenatal Incontinence Pelvic Organ Prolapse Large Baby (>8lbs/3.63kg) Postnatal Depression Pelvic Girdle Pain
How was your birth and how are you doing now? *
During your pregnancy, did you experience any of the following?

Carpel Tunnel Syndrome High Blood Pressure Back Ache Pelvic Girdle Pain Blood Sugar Irregularities Dehydration Oedema Dizziness/Fainting Headache Pelvic Floor Weakness
Were you active/exercising during your pregnancy? If yes, please give details
Please note:
Please wear layers of loose and comfortable clothing, so you can adjust your temperature and you don’t overheat or get too cold during the class and that you don’t feel restricted. Please help yourself to water throughout class as it is important that you remain hydrated during exercise.

Your baby is welcomed to class but you must take responsibility to him/her. You are welcome to toys to entertain or comfort your baby during class. Please feel free to breastfeed and change your baby’s nappy when necessary.
Declaration:
I have answered the questions above to the best of my belief and know of no other reason why I should not undertake a course of exercise. I have disclosed all relevant information and will inform my teacher if my medical condition changes in the future.

I understand that all exercise carries a risk of injury. I accept responsibility for my own body and baby and will stop exercising if I need to I will inform the teacher of any symptoms, physical discomfort or injuries that may arise.

I also understand that my teacher may offer me professional advice relating to adapting particular exercises or to my ability to exercise, and that she may consider it unprofessional to continue to teach me, if I do not wish to follow such advice.
I have read and understood the above statement *

Yes
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Postnatal Pilates- Health Questionnaire

Medical Information