PARQ
Tel: 07813 559 604
PREGNANCY PRE-EXERCISE HEALTH AND LIFESTYLE
QUESTIONNAIRE
Name:
Date:
Address:
Due Date:
No. of weeks pregnant:
No. of children:
Tel No:
Mobile:
Email address:
GP Name:
GP Surgery:
Surgery Tel No:
Midwife Name:
Midwife Tel:
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PARQ
Tel: 07813 559 604
ABSOLUTE CONTRAINDICATIONS TO EXERCISE
Listed below are the current guidelines on ABSOLUTE and RELATIVE
CONTRAINDICATIONS to exercise. Please mark any of the following conditions if you
have experienced them or have been told by your Health Care Professional that you
experience them:
 Significant Heart Disease
☐
 Significant Lung Disease
☐
 Incompetent Cervix
☐
 Multiple gestation at risk of premature labour
☐
 Persistent spotting/bleeding or Placenta Praevia
☐
 Premature Labour
☐
 Ruptured membranes
☐
 Uncontrolled Type 1 Diabetes or Gestational Diabetes
☐
 Evidence of Intrauterine Growth Restriction
☐
 Pregnancy-induced Hypertension or Pre-Eclampsia
☐
 Uncontrolled Epileptic Fits/Seizures
☐
Please provide further information for any marked conditions
2
PARQ
Tel: 07813 559 604
Have you ever experienced any of the conditions listed below whilst exercising during your
current or previous pregnancies?
RELATIVE CONTRAINDICATIONS TO EXERCISE DURING PREGNANCY
 Vaginal bleeding/spotting
☐
 Dyspnoea (difficult or laboured breathing) before exertion
☐
 Dizziness
☐
 Headache
☐
 Chest Pain
☐
 Calf Pain or swelling
☐
 Previous preterm labour
☐
 Previous decreased foetal movement
☐
 ‘Suspected’ Amniotic fluid leakage
☐
 Dramatic recent weight gain
☐
 Swelling or general noticeable appearance of puffiness
☐
 Itchiness
☐
 Noticeable increase in your thirst
☐
Please provide further information for any marked conditions
3
PARQ
Tel: 07813 559 604
Currently, or during previous pregnancies have you suffered any of the following
conditions?
 Symphysis Pubis Dysfunction
☐
 Sacrum or Sacroiliac Joint Pain
☐
 Bleeding/spotting during or after exercise/movement
☐
 Carpal Tunnel Syndrome/Wrist Pain
☐
 Knee Pain
☐
 Low Back Pain
☐
 Upper Back/Neck Pain
☐
 Coccyx Damage or Pain
☐
 Separation of abdominal muscles
☐
 Urinary/faecal incontinence
☐
 Prolapse
☐
 Piles
☐
 Varicose Veins
☐
 Gestational Diabetes
☐
If you develop any of the above health conditions or any other, it is vital that you inform
your fitness instructor and healthcare professional immediately.
Please provide further information for any marked conditions
4
PARQ
Tel: 07813 559 604
List your current (or previous) REGULAR or FAVOURITE fitness/recreational activities and
how often and for how long you perform(ed) them:
Are you currently taking any medication? If
YES, please list
Is there anything in your medical history that
you feel could affect your ability to
exercise?
What are your goals?
Do you have any concerns about your
pregnancy? If so, please comment
DECLARATION
I confirm that I have read and understood this questionnaire and will consult with my GP if
necessary. I confirm that it is my responsibility to ensure the safety of myself and my baby
when participating in any of Henley Pilates’ exercise sessions.
Signature ……………………………………………….. Print Name:……………………………
Date: ………………………….
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