POST NATAL MOVEMENT PRE-SCREENING

Name

First Name

Last Name

Email Address

Address

Phone Number

Emergency Contact Name

Emergency Contact Number

(###)

###

####

Date of Delivery

Type of Delivery

(Assisted/Vaginal/C Section)

6 Week Check Up Date and Outcome

Are you breastfeeding?

If you have stopped please provide when.

Have you been to see a Women's Health Physiotherapist?

If yes please provide contact details and outcome of appointment/s.

Has your period returned?

If so when?

How many children have you given birth to?

Please provide details of birth/s.

Please give details of your Pregnancy & Post Natal journey.

include any complications, illnesses, reasons to visit your Doctor or any other Health Practitioner including Massage, Acupuncture, Pilates, Physiotherapy, Osteopathy, Chiropractor etc.

Did you/ have you suffered with Symphysis Pubis Dysfunction (pain in the central pubic area)

Did you/have you suffered with carpal Tunnel Syndrome (Wrist/finger/hand forearm - pain/numbness or tingling)

Have you/do you suffer with lack of total Bladder/Bowel Control (Urinary or Feacal Incontinence)

If yes please provide details.

Do you or have you suffered with Piles/Haemorrhoids/Varicose Veins/ Constipation

Have you suffered with the after effects of Gestational Diabetes

Have any joint pain?

If yes please provide details.

Have you or do you suffer with sacrum or sacroiliac joint pain (pain in the very low mid back – top of buttocks)?

Have you been diagnosed with prolapse (Uterine, Bladder, Rectum, Vaginal)?

Were you given an Epidural during birthing?

C-Section wound discomfort or slow healing or ongoing numbness?

Bleeding during or after exercise or any unexplained bleeding?

High/low blood pressure, episodes of faintness, dizziness or breathlessness, history of Thrombosis or blood clots?

Diastasis (Separation of your abdominal muscles)?

Have you been diagnosed with a mental condition/illness? If yes please provide details below.

Nerve Damage During Birthing (Especially Pudendal)?

Anaemia or taking Iron medication?

Episiotomy Cut, Painful Perineum or Tears (Degree if known)?

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