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REFORM PREGNANCY QUESTIOANNIRE
First name
Last name
Email
Birthday
Day
Month
Year
Email
Phone
Address
Multi-line address
Country/Region
Address
City
Zip / Postal code
1. Have you ever experienced:
Miscarriage in an earlier pregnancy ?
Other pregnancy complications (in previous pregnancies)?
None of the above
If yes, please explain in more detail
2. Status of current pregnancy During this pregnancy, have you experienced (Tick if you have/Leave blank if NO)
Marked fatigue?
Bleeding from vagina (Spotting)?
Unexplained dizziness or faintness?
Unexplained abdominal pain?
Persistent headache or problems with headaches?
Sudden swelling of ankles, hands or face?
Swelling pain or redness in the calf of one leg?
Absence of fatal movement after 6th month?
Failure to gain weight after 5th month?
None of the above
If answered yes please explain
Due date:
3. Activity Habits; List Only regular activity/recreational activities, Frequency and duration per week
Does your job occupation activity involve Heavy lifting
No
Yes
Frequent walking/stair climbing
No
Yes
Occasional walking (less than once/hour)
No
Yes
Prolonged sitting
No
Yes
Mainly sitting
No
Yes
Normal Daily activity
No
Yes
Do you currently smoke tobacco
No
Yes
Do you consume alcohol
No
Yes
Have you done Reformer or Pilates before? If so when ?
4. Special Consideration for exercise participation PREGNANCY? Absolute Contraindications If answer Yes to any of below You will need medical clearance to partake in pilates by healthcare provided, GP or Consultant. Please give date of clearance
Ruptured membranes or pre term labour?
No
Yes
Persistent 2nd/3rd trimester bleeding/placeta previa?
No
Yes
Pregnancy induced hyper tension or pre-eclampsia?
No
Yes
Incompetent cervix?
No
Yes
Evidence of intrauterine growth restriction?
No
Yes
High order pregnancy ie triplets?
No
Yes
Uncontrolled Type I Diabetes, hypertension or thyroid disease, other serious, cardiovascular, respiratory or systemic order?
No
Yes
5. Relative Contraindications. If answer Yes to any of below You will need medical clearance to partake in pilates by healthcare provided, GP or Consultant. Please give date of clearance below
History or spontaneous abortion, pre term labour in previous pregnancies
No
Yes
Mild/Moderate Cardiovascular or respiratory disease (eg chronic hyper tension, asthma?)
No
Yes
Anemia or iron defficeincy?
No
Yes
Malnutrition or eating disorders
No
Yes
Twin pregnancy after 28th week?
No
Yes
Other significant medical condition, please provide details
If ticked any above please provide details
Privacy and Data Protection (GDPR) You have the right to access your personal data, request correction or inaccurate information, request deletion of data where appropriate, withdraw consent for processing at any time
I have read and understand Privacy and Data Protection statement
I consent to Reform PYP collecting data and processing my personal and health information for the purposes outline above
I confirm that the information provided is accurate to the best of my knowledge. I understand that it is my responsibility to inform Reform PYP of any changes to my health, pregnancy status, symptoms or medical advice.
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I understand that participation in exercise carries a degree of risk and agree to follow the instructions provided by the instructor/physiotherapist.
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