Antenatal registration

We have designed a specific women’s health questionnaire which screens you for a variety of common pregnancy 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 Pilates with us. 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
Email
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*
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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New clients registration Antenatal registration Postnatal registration Children’s registration Outcome measures Oncology rehabilitation registration Clinical Pilates Referral form Hand Held Dynamometry

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© Copyright 2012 - | Designed and Maintained by WPMaintain | All Rights Reserved
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 registration

Please give details of any previous deliveries

Consent

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