Pregnancy Assessment Form

1. Full Name

First NameLast Name

2. Date of birth

MonthDayYear

3. E-mail

4. Phone

5. Baby's Name

6. Baby's Date of Birth

7. Birth Weight

8. Obstetrician

9. Hospital

10. Type of birth

If you had a vaginal birth please complete questions 11 and 12. If you had a casearean go to question 13.

11. Mark the appropriate box

12. Mark the appropriate box

13. Type of Caesarean

14. Brief summary of birth (If vaginal birth include length of pushing phase if known)

include any birth complications or during your hospital stay

15. Is this your first birth

If you answered YES go to quesiton 17. If you answered NO please complete question 16.

16. Obstetric History

Record child's name, age, birth weight, type of birth, complications such as abdominal separation or significant perineal tearing

17. Did you exercise regularly prior to this pregnancy

If you answered YES please complete question 18

18. Outline Exercise program prior to pregnancy (include exercise type and frequency)

19. Did you exercise during your pregnancy

20. Outline Exercise Program during pregnancy or complications that prevented you from exercising

21. Have you returned to any exercise since giving birth

If you answered YES proceed to question 22. If you answered NO go to question 23.

22. Outline the type of exercise and frequency

23. Outline any muscle or joint pain you experienced during pregnancy

Include when it started, severity and whether you had any treatment. If no discomforts please record NIL

24. Outline any muscle or joint issues you are currently experiencing

Include when it started, severity and whether you had any treatment. If no discomfort or pain please record NIL

25. Pelvic Floor Symptoms (are you currently experiencing any of these)

If you experience any of the symptoms listed go to question 26. If you have no pelvic floor symptoms proceed to question 27.

26. Please outline the details of the symptoms you are experiencing and any treatment you have received

include when you first noticed them, severity and any treatment you have had

27. Did a Physiotherapist visit you during your hospital stay

28. Are you aware of whether you have an abdominal muscle separation (diastasis)

If you answered YES complete question 29, otherwise continue to question 30.

29. Approx how large was your separation immediately after birth and now if known

30. Occupation

31. Approx return to work time (if applicable)

32. Where did you here about these classes?

33.Short term goals (next 3-6mths) Please list 1 - 2

Please include at least one goal hope to achieve through attending pregnancy classes

34. Long term goals (next 6-12mths) Please list 1 - 2

35. Are you following the recommended child immunisation program

36. Is there any other information you would like to share before starting classes

Advice offered

Postnatal Assessment Form