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Postnatal QuestionnaireAmy Ford2020-06-24T08:41:54+01:00

Antenatal Questionnaire

Full Name *

Date of birth

Address

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

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

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

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

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby

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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