Postnatal Prescreen

Name

Email

Mobile Phone

Date of delivery

Type of delivery (include details of medication and complications)

Are you breastfeeding?

Yes

No

Do any of these apply to you currently?

Back problems

Pelvic floor problems

Diastasis (seperation of abdominal wall)

Heart problems

Undergone surgery in the last 12 months

High blood pressure

Muscular aches and pains

Prolapse *Uterine, Bladder, Rectum, Vaginal)

C-Section wound discomfort or slow healing or ongoing numbness

Buttock/Piriformis Pain/Sciatica

Bleeding during or ater exercise or unexplained bleeding

High/low blood pressure, episodes of faintness, dizziness or breathlessness

History of thrombosis or blood clots

Breastfeeding issues

Nerve damage during birthing (especially Pudendal)

Anaemia or taking iron medication

Episiotomy cut, painful perineum or tears

Have had an IUD fitted recently

None of the above

Please confirm that you have read and understand my Terms and Conditions indicated below.

Thanks for filling in!

Terms & Conditions

I confirm I am physically fit with no medical conditions or injuries to participate in the exercise program or session.
I assume all risks associated with the exercise and workout programs and for any physical injury or damage that may arise out of my participation.
I indemnify 'Postnatal and beyond' against all liability, including death or damage by participating.

Contact: 0406 975 934