Antenatal Client Health Questionnaire

Antenatal 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*

DayMonthYear
Phone Number

Area CodePhone Number
E-mail Address*
Emergency Contact (Name/Telephone)*
How many weeks pregnant are you?
What is your E.D.D.

DayMonthYear
Date
First baby?

YesSecondThird
What type of delivery do you wish to have?

VaginalCaesareanNot sure
Medical Information
Has you doctor given you permission to exercise?*

YesNo
Did you conceived naturally

YesNo, IVFOther
Have you experienced any of the following?*

Morning SicknessCarpel Tunnel SyndromeHigh Blood PressureBack AchePelvic Girdle PainBlood Sugar IrregularitiesDehydrationOedemaHistory of Pre-eclampsiaDizziness/FaintingHeadachePelvic Floor WeaknessDiabetesOther
Should any of the above symptoms arise during pregnancy please inform the teacher immediately*

Yes. I have read and understood this request
Are you experiencing any antenatal incontinence? Please give details of even minor leaks. *
Are you currently under the care of

a physiotherapistan osteopatha women's health phsyioOther
Are you active/exercising during your pregnancy? If yes, please give details
Anything else I should know about?
What are your aims and expectations in attending Pilates classes?
Previous pregnacy/birth

please skip if doesn't apply
Do you have older children? Please give age and date of birth
What kind of delivery did you have in your most recent birth?

VaginalVaginal with forceps/ventouseEmergency cesareanPlanned cesareanOther
What other deliveries did you have previously?

VaginalVaginal with forceps/ventouseEmergency cesareanPlanned cesareanOther
How was your birth experience last time?
Have you experienced any postnatal incontinence? Please give details of even minor leaks.
Did you have your abdominal muscles checked postnatally for any separation (Diastasis Recti)? What was the outcome of this?
Do you have any concerns about your pelvic floor such as prolapse? Please give details.
Please note:
Should any of the below or other symptoms develop during your pregnancy, please inform me immediately.

o   If you are unwell both emotionally or physical

o   If you are very tired, light headed or feeling faint

o   If you have a high temperature

o   If you have abdominal pain

o   If you have pelvic girdle pain

o   If you feel short of breath

o   If you experience bleeding

o   If you had two or more miscarriages

o   If you experience high blood pressure

o   If you have developed diabetes

o   If you suffer from epilepsy.

o   If exercise causes a burning, achy sensation

o   If you feel dehydrated or have a headache

o   If you experience blurred vision

o   If you are experiencing contractions

o   If you are experiencing fist stage labour

o   If you have compromise cervix

o If you have calf pain or swelling
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
I consent to my details being stored by RePilates and agree to the Data Protection Policy which can be found at the following link-http://www.re-pilates.co.uk/privacy-policy.html*

YesNo
Client Signature*

Clear
Should be Empty:

Antenatal Pilates- Health Questionnaire

Medical Information

Previous pregnacy/birth

Please note: