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Antenatal QuestionnaireAmy Ford2020-06-24T08:41:41+01:00

Antenatal Questionnaire

Full Name *

Date of birth *

Address *

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? *

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

I have read and understand the cancellation policy.

I have read and understand the terms and conditions

I understand the privacy policy.

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