General Health
Name (Initials)
E.g. A.T
Age
Height (cm)
Weight (kg)
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Medical & Health Issues
Have you been hospitalised in the past year?
No
Yes
If yes, please state the length and reason for stay
Smoking Status
Non-smoker
Past smoker
Current smoker
Other
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Past Surgical History
Obstetric History (if relevant)
Rows
Year of delivery
Type of delivery
Episiotomy/Tear?
Weight of Baby
Length of Labour
Other comments/things to note regarding obstetric history
Medications/supplements that you are currently taking:
Rows
Medication/Supplements
Brand
Dosage
Date commenced
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General Exercise
Are you currently participating in any exercise?
No (move on to next question)
Yes (skip next question)
If you have answered "No", what exercises appeal to you and what would you like to do if you could?
e.g. group exercise, swimming, aerobics, running, home-based exercises
If you have answered "Yes", please list the exercises you are currently doing, their frequency and intensity
Rows
Type of Exercise
When did you start it?
Duration (mins)
Rate of Perceived Exertion (see attached picture)
Frequency (no. of times/wk)
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