Pregnancy Assessment Form

Pregnancy Assessment Form
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
E-mail*
Phone*
Due Date*
Obstetrician or Midwife
Hospital
Obstetric history*
Outline if you have experienced any significant events with this pregnancy
Exercise history*
What exercise were you participating in before falling pregnant and what have you been partaking in through your pregnancy to this point
Occupation
Outline any muscle or joint issues you are currently experiencing*
If no discomfort or pain please record NIL
Pelvic Floor Symptoms*

bladder leakageurgency to empty your bladderfeeling of heaviness or dragging vaginallyconstipationurgency to empty bowelsfaecal soilingNone of the above
Please tick off any of the above symptoms that you are currently experiencing. Use the text box below to provide details on your symptoms such as severity, aggravating activities, treatment, etc.
Provide further information on your pelvic floor symptoms. Skip if you have no pelvic floor concerns
Tick any medical condition that applies to you

Heart diseaseLung diseaseIncompetent cervixSevere anaemiaHeavy smokerPoorly controlled seizure disorderAcute infectionUterine bleedingRuptured membranesSuspected foetal growth restrictionType 1 diabetesPoorly controlled hyperthyroidismHigh blood pressureRisk of premature labourPlacenta praeviaNo prenatal careOther
Is this a multiple pregnancy?*

YESNO
Is this your first pregnancy?*

YESNO
If you answered NO in the above question please complete the information below
Number of births
Prior birth history
Please include child AGE, Type of Birth (Vaginal/Caesarian), and any relevant information related to recovery including past abdominal seperation, perineal tearing or pelvic girdle/back pain
Where did you here about these classes?*
Goals you hope to achieve through Classes*
Please include at least one goal hope to achieve through attending pregnancy classes
Any other information you would like to share
Advice offered (Section for Admin to Complete)
Should be Empty: