Pregnancy Exercise Screening Form

Name

Date of Birth

Mobile

Address

Number of weeks pregnant & due date

Emergency Contact - Name & Phone number

Midwife - Name & Phone number

Doctor - Name & Phone number

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

Prior to joining Femmebods have you been doing any regular exercise? Please give details below

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 medications? If so, please specify

Is this your first pregnancy? If no, how many pregnancies have you had?

In the past have you experienced any pregnancy complications? If yes, please give details

Are you experiencing any pain or discomfort from a C-Section scar?

CURRENT PREGNANCY - Are you experiencing any of the following?

Nausea

Constant fatigue

Anaemia or iron deficiency

Upper Back, Shoulder or Neck pain

Carpal Tunnel/Wrist pain

Leg cramps

Symphysis Pubis Pain

Round ligament pain

Buttock, Piriformis or Sciatic Pain

Sacrum or Sacroiliac Joint (SIJ) pain

Bleeding from the vagina (Spotting)

Any degree of Placenta Previa

Unexplained faintness or Dizziness

Unexplained abdominal pain

Sudden swelling, pain or redness in the calf of one leg

Persistent headaches or problems with headaches

Sudden swelling of ankles, hands or face

Varicose veins

Increase in thirst and/or urination

Diaphragm pain or difficulties with Breathing or Acid reflux

Chronic Itching

Incompetent Cervix

Diastasis Recti (Separation of the stomach muscles)

Pelvic floor problems

Urinary problems

Bowel problems

Failure to gain weight after fifth month

Absence of foetal movements after sixth month

If you have answered Yes for any of the above please provide further details here

I, the client have answered the above questions truthfully to the best of my knowledge and will notify my trainer if anything changes

I, the client have discussed my plans to participate in physical activity during my current pregnancy with my healthcare provider (Midwife or Doctor) and I have obtained his/her approval to begin participation.

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.

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

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Pregnancy Exercise Screening Form

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