Postnatal Health Screening & Consent Form

Personal Information

Name:
Date of Birth:
Email:
Phone:
Emergency Contact (Name & Number):

Postnatal Details

Baby’s date of birth:

Type of delivery:

Vaginal birthAssisted vaginal (forceps/ventouse)Caesarean section

Did you experience any complications during labour or delivery?

YesNo

If yes, please provide details:

Do you currently have, or have you had:

Stitches/tearing (perineal or C-section)Pelvic floor weakness (e.g. leaking, heaviness, prolapse)Diastasis recti (abdominal separation) – tested? YesDiastasis recti (abdominal separation) – tested? NoOngoing pain (pelvic, back, abdominal, scar area)Other postnatal concerns (please specify)

Have you had your 6–8 week GP/midwife check-up?

YesNo

Has your GP/midwife/physiotherapist advised you about exercising postnatally?

Cleared for gentle exerciseCleared with modificationsNot yet cleared

Medical History

Please tick if you currently have or have experienced any of the following:

High blood pressure or heart conditionsDiabetes (Type 1, 2, or gestational)Asthma or breathing difficultiesBack or joint problemsPostnatal depression or anxietyOther medical conditions (please specify)

Exercise History

Were you exercising regularly before/during pregnancy?YesNo

Are you currently exercising postnatally?YesNo

If yes, please describe:

Consent & Acknowledgement

• I confirm that I have disclosed all relevant health information and understand that it is my responsibility to inform my instructor of any changes.

• I acknowledge that while every care will be taken, participation in exercise is at my own risk.

• I confirm that I have consulted with my GP/midwife/physiotherapist and have no medical reason to avoid safe, modified postnatal exercise.

I confirm that I have read and understood the above, and I consent to participate in postnatal-safe exercise.

Full Name (typed):
Date:

Legal & Marketing

I confirm that I have read and agree to the Terms and Conditions and Privacy Policy.

Yes, I would like to keep in touch and receive news, exercises, health tips & recipes

🔒 Your information will be kept strictly confidential and used only to ensure safe and appropriate exercise.