MOVE WITH MUMMA ONLINE

Full Name *

First Name Last Name

DOB *

Day Month Year Date Picker Icon

E-mail *

example@example.com

How many weeks / months postnatal are you? *

How would you describe your pregnancy? *

No change Conscious but comfortable Suffered with bad sickness Extreme tiredness A very difficult pregnancy Finished work earlier than expected

Have you had your 6-8 week Postnatal checkup? *

Yes No

Has your GP advised you are safe to exercise? *

Yes No

Birth Information - Please select all that apply *

	Please Select All That Apply
Episiotomy / painful perineum or tears
Stitches present
Traumatic vaginal birth
C-section
None of the above

Health Overview - Please select all that apply *

	Please Select All That Apply
Shortness of breath
Asthma
Seizures
Heart disease
Eating disorder
Gestational diabetes
Chest pain
Carpal tunnel syndrome
Varicose veins
Joint or muscular pains
Low or high blood pressure
Dizziness
Separation of abdominal muscles / Diastasis
Symphysis Pubis Dysfunction
Sacrum or Sacroiliac Joint Pain
Heavy Leakage of Urine
Persistent bleeding
Pelvic Floor Pain
Sign of Infection
Poor healing
Pain - abdominal, pelvic, back or other
Excessive fatigue
Increased pelvic pressure
Painful breasts / breast abscess
Breast discomfort
None of the above

For anything selected above please provide further details and whether it is past or current:

Pelvic Floor - Please select all that apply *

	Please Select All That Apply
Are you experiencing difficulty with your bowel, wind or urinary urges?
Do you lose urinary control when laughing, sneezing, coughing, jumping or moving quickly?
Are your bowel movements or urination painful?
Do you feel any pressure in your vagina or rectum or noticed any protrusions from your orifices?
Do you experience pain with intercourse or sexual stimulation?
Do you currently or have you ever needed to wear incontinence pads?
Do you experience pain inside or at the joints of your pelvis?
Have you ever undergone any gynaecological surgery (e.g.,a hysterectomy, fibroid removal?)
Do you suffer from constipation or regularly strain on the toilet?
Are you incontinent overnight?
NONE OF THE ABOVE

On a scale of 1-10, how much are you troubled by your pelvic floor / continence issues?

	1	2	3	4	5	6	7	8	9	10

1 is A Little, 10 is Very Concerned

Where did you hear about Move with Mumma? *

Would you like to be added to our Move with Mumma mailing list? *

If you selected YES to one or more condition in the health overview section

Talk to your healthcare provided by phone or in person before you start becoming more physically active. Advise your GP about this questionnaire and talk with them about the kind of activity you wish to participate in and always follow their advice.

If you selected 'None of the above' in the health overview section

It is reasonably safe for you to start to become more physically active and take part in a suitable exercise programme. Start slowly and gradually build up your physical activity levels.

IMPORTANT

If your health changes at all or you develop any of the above health conditions, then please inform your instructor and GP / health professional immediately.

Declaration

I confirm that I have read, understood and accurately completed this questionnaire, consulted with my GP if necessary and that it is my responsibility to ensure the safety of myself and my baby when participating in any of the exercises.

This program is not intended to diagnose or treat any illness or injury. It is for educational purposes only. If you choose to try any of the exercises presented here you do so at your own risk. Please consult your physician before you start any new program.

Not every exercise is safe for every person. Correct execution of all exercises is imperative to prevent injury. Please consult your healthcare professional if you have questions about exercise execution or if an exercise is right for you.

You are responsible for yourself and will not hold Amanda Crofts/Move with Mumma Trainers liable for any illness or injury.

Full Name *

First Name Last Name

Signature *

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Date *

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Postnatal Health Form

Declaration