Antenatal Questionnaire

Full Name*
First Last
Date of birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City Post Code Country
Email*
Phone Number
How did you hear about Complete Pilates
Did you participate in any training whilst pregnant?*
- Yes
- No
If so, how often and what kind?
How long was your most recent labour?*
Where did you deliver your baby?*
Have you had a 6 week check? Were there any complications?*
Are you still under the care of a Consultant and if so why?*
Have you had an internal examination?*
- Yes
- No
Are you breastfeeding?*
- Yes
- No
Are you still bleeding?*
- Yes
- No
Do you ever experience leakage of urine and/or stool?*
- Yes
- No
Do you ever feel urgency from the bladder and/or bowel?*
- Yes
- No
Do you suffer from constipation or regularly strain on the toilet?*
- Yes
- No
Do you have any difficulties emptying from the bladder or bowel?*
- Yes
- No
Do you have any difficulty controlling wind?*
- Yes
- No
Do you experience a sensation of pressure or heaviness in your vagina or rectum or ever noticed a bulge inside?*
- Yes
- No
Do you experience pain in your vulva or vagina with or without sex?*
- Yes
- No
Please give details of your delivery and any previous deliveries
Child 1: Date Born

Day
Month
Year
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of heaviest baby
Do you have any other children?
- Yes
- No
Child 2: Date Born

Day
Month
Year
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of baby
Do you have any other children?
- Yes
- No
Child 3: Date Born

Day
Month
Year
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of baby
Do you have any other children?
- Yes
- No
Child 4: Date Born

Day
Month
Year
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of baby
Consent
Consent*
I have read and understand the cancellation policy.*
Consent*
I have read and understand the terms and conditions*
Consent*
I understand the privacy policy.*

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Complete Pilates Medical Ltd registered in England & Wales at 115 Hampstead Road, London, NW1 3EE (for correspondence only), company number: 10206019.
Complete Physio Ltd registered in England & Wales. 18 Church Hill, Winchmore Hill, London, N21 2JB (for correspondence only), company number: 05926168

Antenatal Questionnaire

Please give details of your delivery and any previous deliveries

Consent

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