Home
About
Services
Personal Training
Women’s Group PT
Pre and post natal PT
Nutrition Coaching
Private Yoga Session
Testimonials
Blog
Contact
Fit Strong Mum Pre Natal Screening Questionnaire
Name
(Required)
First
Last
Email
(Required)
Date of birth
(Required)
DD slash MM slash YYYY
Home address
(Required)
Street Address
Address Line 2
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone number
(Required)
Height
Age
Emergency contact 1 name and number
(Required)
Emergency contact 2 name and number
(Required)
How often do you currently exercise?
(Required)
None
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)
(Required)
Circuit training
Weight lifting
Strength and conditioning
Dance fit / aerobics
Exercise to music (body pump, step etc)
High intensity interval training (eg tabata)
Running / other cardio
Sports
What type of exercise do you dislike and why?
(Required)
What are your current goals for exercise and nutrition?
(Required)
Describe how you feel before exercise
Describe how you feel after exercise
How would you like to feel before and after exercise?
(Required)
On a scale of 1-10 where do you feel your current cardiovascular fitness lies?
(Required)
1
2
3
4
5
6
7
8
9
10
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)
(Required)
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?
1
2
3
4
5
6
7
8
9
10
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?
(Required)
Yes
No
How many units of alcohol do you drink per week?
(Required)
0
1-4
5-8
9-12
12+
On average how many hours of unbroken sleep are you getting per night?
(Required)
Looking at yourself both mentally and physically, how happy do you feel?
(Required)
Very happy
Mostly happy
Somewhat happy
Neutral
Mildly unhappy
Very unhappy
Prefer not to say
Are you pregnant now?
(Required)
Yes
No
Is this your first pregnancy?
(Required)
Yes
No
If no, how many pregnancies have you had?
In this or any other pregnancy, have you suffered from any of the following?
(Required)
Fainting
Dizziness
Pelvic pain
Pelvic floor dysfunction
Palpatations
Abnormal bleeding
Lower back pain
Carpal tunnel syndrome
High blood pressure
Gestational diabetes
Chest pain
Insomnia
Delayed growth in baby
Low birth weight
Premature birth
Silent labour
Ectropian of the cervix
Other
None of the above
Do you have any other children
(Required)
Yes
No
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?
Yes
No
NA
Do you feel that you have healed mentally and physically from birth?
Yes
No
Unsure
NA
If no/maybe please give details (if you are comfortable doing so)
Are you currently breastfeeding?
Yes
No
NA I don't have other children
POST BIRTH ONLY - Have your been cleared for exercise by a GP?
Yes
No
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?
Yes
No
NA
Where do you plan to give birth?
Midwife name
Midwife contact number
GP name
GP contact number
Are you under the care of a consultant?
Yes
No
If yes, please give details
Can you think of any reason why it might not be safe for you to undertake an exercise programme?
(Required)
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.
Day
Month
Year
Sign up and receive my free guide