Fit Strong Mum Pre Natal Screening Questionnaire
Date of birth
DD slash MM slash YYYY
Address Line 2
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Emergency contact 1 name and number
Emergency contact 2 name and number
How often do you currently exercise?
Once per week
1-3 per week
3-4 per week
5+ per week
What type of exercise do you CURRENTLY enjoy doing? (tick all that apply)
Strength and conditioning
Dance fit / aerobics
Exercise to music (body pump, step etc)
High intensity interval training (eg tabata)
Running / other cardio
What type of exercise do you dislike and why?
What are your current goals for exercise and nutrition?
Describe how you feel before exercise
Describe how you feel after exercise
How would you like to feel before and after exercise?
On a scale of 1-10 where do you feel your current cardiovascular fitness lies?
What are your current motivations or barriers for exercise (ie why you do it OR why you don't do it?)
Do you have any injuries or illnesses that you feel may inhibit exercise? (please add as much detail as possible)
What is your occupation?
What are your working hours?
How many hours of the day do you spend sitting down? (please include the evening)
On a scale of 1-10 how stressful is your job on a daily basis?
Please describe your eating habits over the length of a full day (please include rough timings of meals and snacks and drinks - be as honest and accurate as possible - there is NO judgement here!)
Do you smoke?
How many units of alcohol do you drink per week?
On average how many hours of unbroken sleep are you getting per night?
Looking at yourself both mentally and physically, how happy do you feel?
Prefer not to say
Are you pregnant now?
Is this your first pregnancy?
If no, how many pregnancies have you had?
In this or any other pregnancy, have you suffered from any of the following?
Pelvic floor dysfunction
Lower back pain
Carpal tunnel syndrome
High blood pressure
Delayed growth in baby
Low birth weight
Ectropian of the cervix
None of the above
Do you have any other children
If yes, please give details of how many and what ages they are
How would you describe your previous pregnancy(s) and birth experience(s)
What type of delivery did you have?
Did you have a tear/episitomy?
Do you feel that you have healed mentally and physically from birth?
If no/maybe please give details (if you are comfortable doing so)
Are you currently breastfeeding?
NA I don't have other children
POST BIRTH ONLY - Have your been cleared for exercise by a GP?
NA I haven't given birth
Describe how you feel your core and pelvic function are doing (this is relevant if you have given birth, but also if you are pregnant for the first time so that we can get a sense of how things are for you now - EG do you have any leaking no matter how small, when you sneeze, cough, run, jump, or do you have any lower back pain?)
Was your diastasis recti (abdominal separation) checked and cleared by a professional post birth?
Where do you plan to give birth?
Midwife contact number
GP contact number
Are you under the care of a consultant?
If yes, please give details
Can you think of any reason why it might not be safe for you to undertake an exercise programme?
Exercise in pregnancy is recommended by the department of health in the UK. It is suggested that a pregnant woman try to remain active for a minimum of 30 minutes per day, or 150 minutes per week. 75 minutes of that time should be dedicated to resistance style training for both maternal health and postnatal recovery. When undertaking an exercise programme with myself or another employee of Fit Strong Mum (Rossell Fitness), it is essential that you are honest and open with us at all times regarding your health, and the health of your unborn child, so that we can keep you safe. Every session that we undertake can be adapted and it is important that we listen carefully to your body and work with how you feel on that day. Even an accompanied walk and a chat can help combat fatigue/morning sickness and general hormone imbalances that come along with pregnancy. It is your responsibility to inform me of any changes to yours or your baby's health that you feel may impact our sessions, as well as any abnormalities such as excess bleeding, feelings of dizziness etc. If you are happy with all of the above, please fill in today's date which will be taken as a legally binding signature.
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