Postnatal Pre-screening Form@thenatalbody ‘Return To Exercise’ class Name * First Name Last Name Email * Mobile Number * Emergency contact (name and number) * Medical history Asthma Epilepsy High blood pressure Low blood pressure Diabetes type 1 or 2 Heart conditions Dizziness/fainting Please list any medical conditions not mentioned above Are you currently taking any medication? Yes No If yes, please detail Pregnancy specific history Did you have any of the following pregnancy related conditions? Pre-eclampsia SPD Diastasis Recti (Abdominal separation) Gestational diabetes Age of your most recent baby/babies? If you have older children please list their ages Postnatal specific history Have you experienced any of the following since giving birth? SPD Back or hip pain Feelings of heaviness or dragging in the vagina Constipation Pelvic floor pain Painful intercourse Incontinence Ongoing vaginal bleeding Diastasis Recti (Abdominal separation) Delayed scar healing What type of delivery/deliveries have you had? Are you breastfeeding? Yes No Did you exercise during pregnancy? Yes No If yes, please detail Are you currently exercising? Yes No If yes, please detail Is there anything else about your pregnancy or post natal journey that you feel might be relevant to participating in this class? Please confirm that you have had the all clear/6 week check with your GP to commence suitable postnatal exercise. * I confirm I have been cleared to exercise It is important that you feel well prior to each class and must notify the instructor should you feel unwell during the class. It is your responsibility to update the instructor of any changes to your health. * I agree Whilst every effort has been taken to ensure this exercise class is suitable for postnatal women, your participation and the safety of both you and your child/children is your responsibility. * I understand Data Protection: The information you provided in this form will be used for my purposes only and will not be shared with any third party without your prior permission. Any information you do provide will be stored for 5 years. * I agree If you or any members of your household have tested positive for Covid 19 or are symptomatic, please do not attend class. * I understand Thank you!
