Post natal questionnaire - Rossell Fitness

Name*

First Last

Email*

I need your email address to send you a copy of your answers to the questions

Date of birth*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone number*

Height

Age

Emergency contact name*

First Last

Relationship to you*

Emergency contact phone*

Emergency contact 2 name*

First Last

Relationship to you*

Emergency contact 2 phone number*

How often do you currently exercise?*

I don't currently do any planned exercise
Once per week
1-3 per week
3-4 per week
5+ per week

What type(s) of exercise do you enjoy?*

What type of exercise do you dislike and why?*

What are your current goals for nutrition and exercise?*

Describe how you feel before exercise*

Describe how you feel AFTER exercise?*

How would you like to feel during AND after exercise?*

On a scale of 1-10, where do you feel your current level of cardio-vascular fitness is?*

What are your current barriers for exercise?*

e.g. time, money, family commitments, work, health, joint pain etc

Do you have any injuries or illnesses that you feel might inhibit exercise?*

What is your occupation?*

What hours are restricted for you due to your occupation?*

How many hours do you spend sitting down per day?*

On a scale of 1-10 how stressful is your occpation?*

Please describe your eating habits over a full day, including all snacks and drinks

Try to be as honest as possible, there is no judgement here <3

Do you smoke?*

Yes
No

How much alcohol do you consume 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 at the moment?*

If you could have one superpower, what would it be and why?*

Are you currently, or could you be pregnant?*

Yes
No
Not sure

Do you have any children?*

Yes
No

Please give details of their age(s)*

How would you describe your pregnancy and birth experience?*

Do you feel that you have healed mentally and physically from your birth(s)?*

Yes
No
Maybe

If no/maybe, please give details*

Are you currently breastfeeding?*

Yes
No

What type of delivery did you have?*

Did you have a tear/episiotomy?*

Yes
No

Please give details*

Was your diastasis recti (abdominal separation) checked and cleared by a professional post birth?*

Yes
No

Please give details (i.e level of separation at birth, level of separation now)*

Have you been cleared for exercise by your GP?*

Yes
No

Describe how your core/pelvic floor function has been since the delivery (do you have any leaking, no matter how small, when sneezing, coughing, running or jumping?)*

Do you have any lower back pain?*

Yes
No

Did you have any pelvic pain in pregnancy?*

Yes
No

If YES please give details*

Do you feel like this has been resolved now?*

Yes
No
N/A

Describe what your support system is like at home*

In order to undertake an exercise programme with me you must have been cleared for exercise by a GP, following the appropriate rest time for your birth and delivery. It is essential that you are honest with me about how your body feels at any point in your training programme and you must not ignore any signs of dysfunction in your pelvic floor such as leaking, gripping pain, abdominal cramps or lower back or thigh pain. You are welcome to bring your child along to our sessions as long as they are happy to stay in their pram/car seat. I will endeavour to keep you both safe, but you must assume 100% of the responsibility for the health and well-being of your child. If you are happy with all of this please check the box below.*

I am happy with these conditions

Post natal screening questionnaire