Prenatal Online ConsultationThe following consultation should only take a few moments. Please answer all questions to the best of your knowledge. Begin Consultation Prenatal Consultation Name * First Name Last Name Date of birth (month first) MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number Email * Due Date (month first) * MM DD YYYY What are your goals & objectives? * General Health Please read the following questions carefully and answer each one honestly. If you have any questions, please ask for advice. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Select Yes No Do you feel pain in your chest when you do physical activity? Select Yes No In the last month, have you had chest pain when you were not doing physical activity? Select Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Select Yes No Have you had an asthma attack requiring medical attention at any time over the last 12 months? Select Yes No If you have diabetes, have you had trouble controlling your blood glucose at any time over the last 6 months? Select Yes No Do you have a bone or joint problem that could be made worse by participating in exercise? Select Yes No Have you had surgery in the past 6 months? Select Yes No Is your doctor currently prescribing drugs for your blood pressure or a heart condition or other serious illness? Select Yes No Do you have any other medical condition or know of any other reason (including the following) that may make it dangerous for you to participate in exercise? Select Yes No Pre-Exercise Health Checklist 1. Is this your first pregnancy? Select Yes No If NO, how many pregnancies have you had? 2. In the past have you experienced miscarriage in an earlier pregnancy? Select Yes No If YES, please give details 3. In the past have you experienced other pregnancy complications? Select Yes No If YES, please give details 4. Are you/were you a regular exerciser before becoming pregnant? Select Yes No If YES, please give details Status of Current Pregnancy Are you experiencing any of the following? Marked fatigue Bleeding from the vagina (spotting) Unexplained faintness or dizziness Unexplained abdominal pain Sudden swelling, pain or redness in the calf of one leg? Persistent headaches or problems with headaches? Sudden swelling of the ankles, hands or face Absence of foetal movements after sixth month Failure to gain weight after fifth month If you have answered YES to any of the above questions, please give details: Exercise List any fitness/recreational activities Does your regular occupation (job/home) activity involve? Heavy lifting Frequent walking/stair climbing Occasional walking (once an hour) Prolonged standing Mainly sitting Normal daily activity Do you currently smoke tobacco? Do you currently consume alcohol? Terms and conditions IF YOU ANSWERED YES to one or more questions*: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. IF YOU ANSWERED NO to all questions: You can be reasonably sure that it is safe for you to participate in physical activity, gradually building up from your current ability level. ------- “I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury”. *Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise. PLEASE ENTER TODAY'S DATE (month first) MM DD YYYY Thank you! GDPR noticeAll personal data is collected, transmitted and stored in accordance with my privacy policy. It is not shared with any other individual or company.