postnatal exercise screening form

Name

Date of Birth

Address

Mobile

Emergency Contact - Name & Phone number

Delivery Date

Midwife - Name & Phone number

Doctor - Name & Phone number

6/8 weeks check up outcome

Other professionals currently involved in care (Osteo, physio etc)

WHICH OF THE BELOW APPLIES TO YOUR DELIVERY

Normal Vaginal Delivery

Ventouse (Vacuum Device)

Forceps

Cesarean

Tears

Episiotomy

Are you still breastfeeding?

Is this your first birth? If no, how many times have you given birth? Please provide any significant details of each birth

Have you recently had an IUD fitted?

HAS PREGNANCY OR BIRTH LED TO ANY OF THE FOLLOWING

Current or previous pelvic floor issues

Current or previous urinary problems

Current or previous bowel problems

Cesarean Scar pain or discomfort

Any unexplained bleeding

Anaemia

Diastasis Recti (Separation of the abdominal muscles)

Symphysis Pubis Dysfunction

Deep vein thrombosis (DVT)

If you have selected any of the above please provide details here

Is there any other ailments you have experienced during your pregnancy & into the postnatal period including any reasons to visit the doctor, ask the advice of your midwife or any other health practitioner.

What are your main goals, aims or reasons for starting with FemmeBods?

Prior to and during your most recent pregnancy were you participating in any regular exercise? If so, what?

GENERAL HEALTH - Do you have any of the following

Heart Condition

Chest pain when exercising

Loss of balance due to dizziness

Back, Pelvic or other joint pain that could be made worse by exercise

Previous muscular or joint injury

High or low blood pressure

Diabetes

Epilepsy or a history of fits

Asthma

Current or previous eating disorder

Constipation/IBS/Coeliac or Crohn's disease

If you have selected any of the above, please provide details here

Have you had any major sugeries or other physical trauma?

Do you smoke? If so, how much

Are you taking any medication? If so, please specify

I, the client have answered the above questions truthfully to the best of my knowlege

I, the client have been given the ok to participate in physical activity following my most recent pregnancy/birth by my healthcare provider (Midwife or Doctor)

During exercise sessions every effort is made to keep the session safe and minimise risks whilst providing an effective session. I, the client, am participating of my own free will and am aware, as with any exercise programme, there is a risk of injury. If I am feeling any discomfort or uncertainty throughout a session I will stop immediately and consult the trainer. I will not hold Femme Bods or staff liable in any way for injuries or illness that may occur while I am training.

I understand that occasionally photographs will be taken for advertising and promotion. I am happy for pictures of me to be used for these purposes.

Which training option are you interested in? Eg: Reconnect, Mums Club or Personal Training

Best time to contact you if necessary to discuss your screening form

Address

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Postnatal Exercise Screening Form

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