Bespoke Postnatal PT Questionnaire Postnatal Pre-Activity Health Questionnaire Please answer all questions then click Send at the bottom of the form. Your completed form will be emailed directly to me and will be treated in full confidence. You will receive an email of your completed form acknowledging its receipt. At your 6-8 week check-up did you receive medical clearance to exercise? YesNo Current date Telephone Name Email Address 6-8 week check-up date Date you gave birth Type of birth ---AssistedVaginalC-Section Epidural YesNo Dates of previous pregnancies (from-to): Postnatal bleeding status: Breastfeeding status: Recently fitted IUD? YesNo Have you suffered from any of the following? Please tick all that apply and provide details in the box below. Symphysis Pubis Dysfunction (pain in the front area of the pelvis)Carpal Tunnel syndrome (pain, numbness or tingling in the wrist, hand or fingers)Upper back/neck/shoulder painLack of total bladder or bowel control (Urinary or Faecal Incontinence)Haemorrhoids (Piles), Varicose Veins, ConstipationAfter-effects of Gestational DiabetesJoint painSacrum or Sacroiliac Joint Pain (pain the mid lower back, top of buttocks)Knee pain (side/front)Coccyx damage or painProlapse – Bladder, Rectum, Vaginal, UterineC-Section wound discomfort, slow healing, ongoing numbnessEpiscitomy (cut) during birthing, degree if knownEpiduralButtock pain or SciaticaAny unexplained bleeding including during or after exerciseHigh or low blood pressure, episodes of faintness, dizziness or breathlessnessHistory of Thrombosis or blood clotsBreast health or breastfeeding issuesDiastasis Recti (separation of your abdominal muscles)Nerve damage during birthingAnaemia or taking iron supplements Please give details of your health during your pregnancy and since giving birth. Include all illnesses, injuries and any reasons you have had to visit any health professional. Please tell me in what ways you require my help. Write freely, in as much detail as possible including how you feel, your concerns, your health and fitness goals.