Legs, BumsMums

Exercise Screening Questionnaire

Name                                            Babies Name                                                                       

Tel No:                                          Address.                                                                                                                                                                                           

 Email                                                                                                                   

Babies Date of Birth & age of your baby (in weeks) by the first session of the

Course                                                                                                                

Type of delivery       normal/……………….  Caesarean/……………..

Please take the time to complete this questionnaire as you register for your course and hand it in to your instructor. 

Regular exercise activity is fun & healthy, especially following childbirth. However, I recommend that you complete this questionnaire & check with your doctor before embarking on any new activity program.

Please answer the following questions as clearly as possible.  IF YOU ANSWER YES PLEASE GIVE DETAILS

Has your doctor ever said you have a heart condition?    YES    NO 

Do your feel pain in your chest when you do any physical activity? YES    NO                                                                                                  

In the last month, have you had chest pain when you were not doing physical activity YES   NO                                                                  

Do you lose your balance because of dizziness or do you ever lose consciousness?    YES    NO                                                              

Do you have a back/pelvic or other joint problem that could be made worse by a change in your physical activiy?    YES    NO              

Do you suffer from raised blood pressure? YES     NO If YES

Do you suffer from diabetes? YES     NO If YES

Do you know of any other reason that could affect your participation in exercise?                                                                                         

Are you asthmatic? ……………..  If yes - is it exercise induced?  PLEASE BRING YOUR INHALER TO THE CLASS.

Are you an insulin dependent diabetic?                                                                

Have you had your 6 week check?   Any Problems?                               

 INFORMED CONSENT:

I confirm that I have answered all the above questions honestly & to the best of my knowledge.

I confirm that I will advise my Legs,Bums & Mums instructor of any changes in my physical condition.

I understand that I am responsible for the welfare of my baby during the class, I will ensure that my baby is strapped in correctly throughout the class & will not participate in any activity that I feel is not safe with my baby.

Signed_______________________________________________

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