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*
Telephone No*
How did you hear about Complete Pilates*
Did you participate in any training whilst pregnant? If so, how often and what kind?*
How many weeks pregnant are you?*
What is your due date?*
DD dash MM dash YYYY
Where are you having your baby?*
Where are you receiving your midwifery care?*
Are you under the care of a Consultant? If so who*
Are you expecting twins or triplets?*
- Yes
- No
Have you had any scan results? If so what were the results?*
Do you have a cervical stitch in place?*
- Yes
- No
Has your pregnancy been assisted in any way (e.g. IVF)?*
- Yes
- No
Do you have gestational diabetes?*
- Yes
- No
Have you ever had a placenta praevia?*
- Yes
- No
Do you have a low lying placenta?*
- Yes
- No
Have you ever had a miscarriage?*
- Yes
- No
Please give details of any previous deliveries
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Child 1 Age
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
What is the weight of your heaviest baby?
Do you have any other children?*
- Yes
- No
Child 2 Age
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of baby
Do you have any other children?
- Yes
- No
Child 3 Age
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of baby
Do you have any other children?
- Yes
- No
Child 4 Age
Method of delivery e.g. vaginal, caesarean, forceps, ventouse
Any complications
Weight of baby
Are you planning on having anymore children?*
- 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 pain in your vulva or vagina with or without sex?*
- Yes
- No
Do you experience a sensation of pressure or heaviness in your vagina or rectum or ever noticed a bulge inside?*
- Yes
- No
Have you experienced any of the following: (Please tick)*
- Reduced foetal movement?
- Bleeding from the vagina?
- Severe nausea / vomiting?
- Altered sight e.g. flashing lights?
- Chills or fever?
- High or low blood pressure?
- A feeling of pelvic pressure?
- Abdominal pain?
- Trauma to your abdomen?
- Severe headache?
- A persistent body itch?
- Painful or burning urination?
- Severe constipation?
- Swelling or puffiness of the face?
- Fainting or dizziness?
- Lower back pain?
- Leg cramps?
- None of these symptoms
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 any previous deliveries

Consent

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