mums and Bums And Tums
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Date of delivery:
Type of Delivery
Were you given an epidural during birthing?
Please give details of your pregnancy & post natal, including and complications, illnesses, reasons to visit your Doctor or any other health practitioner including massage, acupuncture, plates, physiotherapy, osteopathy etc.
Do you currently have, or have you ever suffered from any of the following conditions?
Symphysis Pubis Dysfunction (pain in the central pubic area)
Sacrum or Sacroiliac Joint Pain (pain in the very low mid back–top of buttocks)
Bleeding during or after exercise or any unexplained bleeding
Carpal Tunnel Syndrome Wrist/finger/hand forearm-pain/numbness or tingling)
Anaemia or taking Iron medication
Joint Pain / Muscle Pain
Prolapse (Uterine, Bladder, Rectum, Vaginal)
C Section wound discomfort or slow healing or ongoing numbness
Cut, Painful Perineum or Tears (Degree if known)
Knee Pain (Side, front or back)
Breast Health/Breast Feeding Issues/Mastitis
Do you know of any reason why you should not do physical activity - including suffering from chest pain, dizziness, lose consciousness, bone or joint problem, blood pressure or heart condition?
If yes, please comment:
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise and my participation involves a risk of injury.
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