test captcha

Name*

Email*

DOB

ADDRESS

Due Date

CONSULTANT/DOCTOR

HOSPITAL

Phone

NAME OF CONTACT:

RELATIONSHIP

TEL NO

ALTERNATIVE TEL NO

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

Has your doctor ever said that you have a heart condition? If YES, please give details.

Yes
No

Do you feel pain in your chest when you do physical activity?

Yes
No

In the past month, have you had chest pain when you were not doing physical activity?

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes
No

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

Yes
No

Do you suffer from raised blood pressure? If YES, is this pregnancy related and how is it being treated?

Yes
No

Do you suffer from diabetes? If YES, is this pregnancy related and how is it being treated?

Yes
No

Do you suffer from asthma? If YES, how is this controlled?

Yes
No

Do you know of any other reason that could affect your participation in exercise?

Yes
No

B - Pre-exercise health checklist

General health status

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

Yes
No

In the past have you experienced miscarriage in an earlier pregnancy? If YES, please give details

Yes
No

In the past have you experienced other pregnancy complications? If YES, please give details

Yes
No

Are you/were you a regular exerciser before becoming pregnant? If YES, please give details

Yes
No

Status of current pregnancy

Are you experiencing any of the following?

Marked fatigue

Yes
No

Bleeding from the vagina (spotting)

Yes
No

Unexplained faintness or dizziness

Yes
No

Unexplained abdominal pain

Yes
No

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

Yes
No

Persistent headaches or problems with headaches?

Yes
No

Sudden swelling of the ankles, hands or face

Yes
No

Absence of foetal movements after sixth month

Yes
No

Failure to gain weight after fifth month

Yes
No

Is this Pregnancy

Singleton Pregnancy
Twins Pregnancy
Triplet Pregnancy

Heavy lifting

Yes
No

Frequent walking/stair climbing

Yes
No

Occasional walking (once an hour)

Yes
No

Prolonged standing

Yes
No

Mainly sitting

Yes
No

Normal daily activity

Yes
No

2. Do you currently smoke tobacco?

Yes
No

3. Do you currently consume alcohol?

Yes
No

Physical activity intentions

What physical activity do you intend to do?

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

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

ANTENATAL EXERCISES