Post Natal Client Questionnaire

Name *

First Name

Last Name

Have you received approval from your GP to resume (or start) exercising? If no please gain this before our first session. *

Yes

No

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2. Do you ever feel pain in your chest when you do physical activity? *

Yes

No

3. Have you ever had chest pain when you were not doing physical activity? *

Yes

No

4. Have you had a stroke? *

Yes

No

5. Do you ever feel faint, have spells of dizziness or lose consciousness? *

Yes

No

6. Do you have a spinal or orthopaedic condition that could be made worse by exercise? *

Yes

No

7. Do you have a neurological condition? *

Yes

No

8. Have you ever been told that you have high or low blood pressure? *

Yes

No

9. Do you have asthma or have ever suffered from shortness of breath at rest or with mild exertion? *

Yes

No

10. Do you have Diabetes? *

Yes

No

11. Did you suffer any problems or complications during pregnancy? *

Yes

No

12. Did you suffer any problems or complications during delivery or after? *

Yes

No

13. What type of delivery did you have? *

Vaginal Delivery

Planned C-Section

Emergency C-Section

14. Have you had your post-natal check-up? *

Yes

No

14a. Was everything satisfactory?

Yes

No

15. Has the Diastasis Recti check been performed? *

Yes

No

16. Has post-partum bleeding ceased? *

Yes

No

17. Did you exercise during pregnancy? *

Yes

No

18. Are you experiencing pain whilst seated? *

Yes

No

From time to time AM Pilates London would like to send you emails including offers, news, class timetable updates. Please select below whether you would like to receive these. *

Yes

No

By inputting my name below I confirm I have read, understood and accurately completed this questionnaire. I confirm that I have acted on any issues arising from the questions and have obtained medical advice where required. I confirm I have been cleared to exercise by my GP or medical practitioner. I confirm that I will inform my instructor if any of this information changes. I realise that by participating in a Pilates class I may be at risk of injury and I hereby confirm that I am participating voluntarily. *

I confirm