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FITMUMS – Prenatal & Postnatal Health Form
What service are you interested in?
(Required)
Pregnancy / Prenatal Fitness
Postnatal Fitness
Other
Name
First
Last
Date of Birth
Day
Month
Year
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
Day
Month
Year
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…?)
No
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?
No
Yes - Before Pregnancy
Yes - During Pregnancy
Did you exercise before and/or during your pregnancy?
No
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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