Post-natal registration form

We have designed a specific women’s health questionnaire which screens you for a variety of common post-natal conditions. You may find some of the questions quite detailed but this is so that we can ensure you are with the best possible instructor. With this information we can also let you know whether you need to see one of our pelvic health physio’s prior to beginning exercise. If you are unsure about any of these questions, or would prefer to speak to someone directly, please contact us.

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Name*
First Last
Email*
Phone
What can we help you with?
Message*
What is the capital of France*
- London
- Paris
- Cape Town
Phone
This field is for validation purposes and should be left unchanged.

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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New clients registration Antenatal registration Postnatal registration Children’s registration Outcome measures Oncology rehabilitation registration Clinical Pilates Referral form Hand Held Dynamometry

0203 764 5668

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Angel
London
N1 0QH

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37-39 Lime Street
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EC3M 7AY

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321 Fulham Road
London
SW10 9QL

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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

Post-natal registration form

Please give details of your delivery and any previous deliveries

Consent

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