Birth Date * MM DD YYYY Name * First Name Last Name Phone Number (###) ### #### Email * Date Of Delivery MM DD YYYY Type Of Delivery Assisted, Vaginal, C-Section Breastfeeding Status Postnatal Bleeding Status Do You have A Recently Fitted Intra Uterine Device (IUD)? Details Of Pregnancy/Postpartum Include any complications, illnesses, reasons to visit your Doctor or Health Practitioners. This can include Physiotherapist, Chiropractor etc. Do You suffer From Any Of The Following Conditions? Please select if you have suffered from these in the past. Carpel Tunnel Syndrome Upper Back/Neck/Shoulder Pain Incontinence (Urinary or Faecal) Piles/Haemorrhoids/Varicose Veins/Constipation Gestational Diabetes Joint Pain/Muscle Pain Symphysis Pubis Dysfunction Knee Pain (Side, Front Or Back) Coccyx Damage Or Pain Prolapse (Uterine, Bladder, Rectum, Vaginal) Given An Epidural During Birth C-Section Wound Discomfort Or Slow Healing Buttock/Piriformis Pain/Sciatica Sacrum Or Sacroiliac Joint Pain High/Low Blood Pressure, Dizziness, Faintness, Or Breathlessness Breast Health/Breastfeeding Issues (Mastitis) Nerve Damage During Birth (Pudenal) Anaemia Or Taking Iron Medications Episiotomy Cut, Painful Perineum Or Any Unexplained Bleeding Bleeding During Or After Exercise Or Any Unexplained Bleeding Please Detail Any Relevant/Important Information Relating To Previous Pregnancies And Post Birth Periods. such As Periods Of Illness Or Negative Outcomes Are You Able To Count On Your Significant Others During This Journey? Can You Briefly Detail Your Previous Exercise Abilities/Activities? Which Fitness Activities Do You Dislike? On A Scale From 1-10 Can You Rate Your Degree Of Focus And Intention To Achieve Your Current Goals? (1 Being The Lowest, 10 Being The Highest) Tick Only The Ones That Apply To You Your Doctor Has Mentioned You Have Heart Problems You Have Previously Had Chest Pains Or Been Short Of Breath You Have Previously Felt Faint Or Dizzy Your Doctor Has Mentioned That Your Blood Pressure Is To High You Have Joint Problems You Have Been Hospitalised In The Last 3 Years You Are Pre/Post Natal You Suffer From Asthma/Breathing Difficulties You Suffer From Diabetes You Suffer From Epilepsy You Have Allergies You Have A Chronic Illness You Have A Family History With Major Health Problems You Have Been Sick In The Last 3 Weeks Please Provide Further Details Here If You Selected Any Of The Above If You Are Taking Any Medications Or Supplements Please List Them Here Do You Have Any Old Injuries Or Previous Medical Conditions, Surgery, etc That You Have No Current Symptoms From? What Are Your Goals For The Next 12 Week Program? Motivation Level I Am Extremely Motivated For This Program Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you for completing our pre-screening form!We’re so excited to welcome you to the Bondi Mums community and can’t wait to have you with us! 💛
