Reform Restore Questionnaire

First name

Last name

Email

Phone

Birthday

Day

Month

Year

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Multi-line address

Country/Region

Address

City

Zip / Postal code

Baby's Date of Birth/Age

Delivery Type

Spontaneous Vaginal

Assisted (Forceps/Ventouse)

Elective C-Section

Emergency C-Section

Section 1: Postnatal Review & Delivery

Please check Yes or No

1. Have you had your 6-8 week postnatal check with your GP? If no clearance is required prior to commencing structured exercise.

Yes

No

2. Did you experience birth Trauma or complication (e.g. 3rd or 4th Degree perineal tear, episiotomy, major blood loss, or wound infection)?

Yes

No

3. If you had a C- section or perineal tear, is your wound fully healed with no persistent pain, discharge, or redness?

Yes

No

Section 2; Pelvic health & Core function

Please check Yes or No

4. Do you experience any involuntary leakage of urine, wind, or stool (e.g. when coughing or laughing or exercising)?

Yes

No

5. Do you feel a sensation of heaviness, dragging, or a bulge in your vagina or pelvic area? (Potential sign of Pelvic Organ Prolapse)

Yes

No

6. Do you notice any 'doming', 'coning' or a viable ridge along the midline or your stomach during movement? (Diastase Recti Abdominals DIA)

Yes

No

7. Are you experiencing ongoing Pelvic Girdle Pain (PGP), pubis symphysis pain, lower back pain, or joint pain?

Yes

No

8. Have you noticed an unexpected increase in bright red vaginal bleeding (loch) after activity?

Yes

No

Section 3; General Health & Cardiovascular Screen

Please check Yes or No

9. Do you experience dizziness, light- headedness, faintness, or shortness of breath (especially when lying flat)?

Yes

No

10. Do you have pain, heat, or swelling in one calf or leg? (Requires Urgent assessment for VTE or DVT)

Yes

No

11. Has your Doctor , midwife, or health visitor advised you NOT to exercise at this stage?

Yes

No

12. Are you currently breastfeeding/chestfeeding? (to assist with hydration, bra support, and bon health consideration)

Yes

No

Action & Referral Framework

Clearance to exercise

If answered YES to Section 1 and NO to Section 2, you may begin a gradual, progressive return to exercise in line with UK Chief Medical Officers (CMO) postnatal Guildelines

Clinical Assessment Recommendations

If you answered YES to any of Section 2, we recommend an assessment with an NHS or specialist Pelvic Physiotherapist before starting high impact activity or heavy lifting

Medical Referral Required

If you answered YES to Section 3 - Please pause exercise and consult your GP or Midwife

Declaration & Informed Consent

I confirm that the information provided above is accurate to the best of my knowledge

I agree to inform my instructor/physiotherapist immediatley if any new symptoms arise during or after exercise (including pelvic pressue, pain, or incontinence)

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

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Day

Month

Year

Long answer

REFORM RESTORE QUESTIONNAIRE