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    Regular physical activity is fun and healthy, especially during pregnancy. However, we would recommend that you complete and check this questionnaire with your doctor before embarking on any new activity programme.

    When answering the following questions, common sense is your best guide. Please read the questions carefully and answer each one honestly. (All responses will be treated with the strictest of confidence).

    A - General Health

    1. Has your doctor ever said that you have a heart condition? If YES, please give details.
    2. Do you feel pain in your chest when you do physical activity?
    3. In the past month, have you had chest pain when you were not doing physical activity?
    4. Do you lose your balance because of dizziness or do you ever lose consciousness?
    5. Do you have back/pelvic or other joint problem that could be made worse by a change in your physical activity? If, YES please give details
    6. Do you suffer from raised blood pressure? If YES, is this pregnancy related and how is it being treated?
    7. Do you suffer from diabetes? If YES, is this pregnancy related and how is it being treated?
    8. Do you suffer from asthma? If YES, how is this controlled?
    9. Do you know of any other reason that could affect your participation in exercise?

    B - Pre-exercise health checklist

    General health status

    1. Is this your first pregnancy? If NO, how many pregnancies have you had?
    2. In the past have you experienced miscarriage in an earlier pregnancy? If YES, please give details
    3. In the past have you experienced other pregnancy complications? If YES, please give details
    4. Are you/were you a regular exerciser before becoming pregnant? If YES, please give details

    Status of current pregnancy

    Are you experiencing any of the following?

    1. Marked fatigue
    2. Bleeding from the vagina (spotting)
    3. Unexplained faintness or dizziness
    4. Unexplained abdominal pain
    5. Sudden swelling, pain or redness in the calf of one leg?
    6. Persistent headaches or problems with headaches?
    7. Sudden swelling of the ankles, hands or face
    8. Absence of foetal movements after sixth month
    9. Failure to gain weight after fifth month

    If you have answered YES to any of the above questions, please give details:

    Status of current pregnancy

    List only regular fitness/recreational activities:

    1. Does your regular occupation (job/home) activity involve:
      • Heavy lifting
      • Frequent walking/stair climbing
      • Occasional walking (once an hour)
      • Prolonged standing
      • Mainly sitting
      • Normal daily activity
    2. Do you currently smoke tobacco?
    3. Do you currently consume alcohol?

    Physical activity intentions

    Note: Pregnant women are strongly advised not to smoke or consume alcohol during pregnancy and lactation.

    C - Contraindications to exercise: to be completed by your healthcare professional

    Absolute contraindications

    Does the patient have:

    1. Ruptures membranes, premature labour
    2. Persistent second or third trimester bleeding/placenta praevia
    3. Pregnancy-induced hypertension or pre-eclampsia
    4. Incompetent cervix
    5. Evidence of intrauterine growth restriction
    6. High-order pregnancy (triplets)
    7. Uncontrolled type-I diabetes, hypertension or thyroid disease, other serious cardiovascular respiratory or systemic diseases

    Relative contraindications

    Does the patient have:

    1. History of spontaneous abortion or premature labour in previous pregnancies
    2. Mild/moderate cardiovascular or respiratory disease (eg, chronic hypertension, asthma)
    3. Anaemia or iron deficiency
    4. Malnutrition or eating disorder
    5. Twin pregnancy after 28th week

    NOTE: risk may exceed benefits of regular physical activity. The decision to be physically active or not should be made with qualified medical advice.

    Physical activity recommendation

    1. Recommended/approved:
    2. Contraindicated:

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