Fit Mums – Prenatal & Postnatal Health Form

What service are you interested in?(Required)

Pregnancy / Prenatal Fitness

Postnatal Fitness

Other

Name

First Last

Date of Birth

Email(Required)

Phone(Required)

Do you currently have a Due Date? Or what is your estimated due date?

Baby's Name

Baby's Date of Birth

Hospital Delivered at:

Pregnancy & Birth & Beyond

Do you have any of the following conditions?

Heart Disease

Epilepsy

Asthma

Diabetes

High Blood Pressure

Other Respiratory Disease

History of Prolapse

Less than 6 Weeks Post-Birth

How many pregnancies have you had?

How many children do you have?

What type of delivery / deliveries did you have (include detail of tears/episiotomy/vacuum/forceps)?

Have you experienced any challenges/medical issues during your pregnancy (high blood pressure, carpal tunnel syndrome, pelvic instability, type of delivery…?)

Yes

If Yes, please give a brief description below

Exercise History & Current Goals

Do you currently suffer from any of the following musculoskeletal complaints?

Back Pain

Bladder Problems

Dizziness

Knee Pain

Pelvis Pain

Wrist Pain

Do you have any other medical or musculoskeletal condition/injury?

Have you seen a physio/osteo or a medical professional since being pregnant? If yes, was there any specific guidelines given…

Did you exercise before and/or during your pregnancy?

Yes - Before Pregnancy

Yes - During Pregnancy

Did you exercise before and/or during your pregnancy?

Yes - Before Pregnancy

Yes - During Pregnancy

Yes - After Pregnancy

Can you give a brief overview of what exercise you have been doing?

Are there any other details you'd like to add about your pregnancy so far?

Please don't hesitate to add any other details for our team.

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Fit Mums – Prenatal & Postnatal Health Form

Pregnancy & Birth & Beyond

Exercise History & Current Goals

Speak to the MV Fit Trainer Team Today