Pre-Registration

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Pre-activity Questionnaire
Netmums Winner
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Name

Address Line 1

Address Line 2

Town/City

Postcode

Phone

Date of delivery:

Type of Delivery Assisted Vaginal C-Section

Were you given an epidural during birthing? Yes No

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

Buttock/Piriformis Pain/Sciatica

Prolapse (Uterine, Bladder, Rectum, Vaginal)

Piles/Haemorrhoids/Varicose Veins/Constipation

C Section wound discomfort or slow healing or ongoing numbness

Episiotomy

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? Yes No

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.