EmailMe Form - PREGNANCY ASSESSMENT FORM (ANTENATAL )

Name *
First Last
Address *

Street Address City State / Province / Region Postal / Zip Code
Phone *
Email address *
Todays Date *
DD / MM / YYYY
Mothers Birthday i.e. your birthday *
DD / MM / YYYY
Mothers age *
Your expected ;delivery date *
DD / MM / YYYY
Which maternity hospital are you attending *
Are you under any of the following teams? *
Multiples
Midwife Clinic
Combined care with GP
Diabetic clinic
High Risk Clinic
Other, please give details
GP name and location. e.g. Dr Smith, Celbridge.
How long did it take for you to become pregnant *
Weeks
0-6 months
6-12 months
1 year+
Other
What type of delivery are you planning *
Vaginal Delivery (VD)
Planned elective Caesarean Section (CS)
VD but have had a previous CS
Not sure yet
This is a single or multiple Pregnancy *
Single Baby
Twins
Multiples
Have not had a scan yet to confirm
Is this your first pregnancy? *
First Pregnancy
Second Pregnancy
Third Pregnancy
Fourth Pregnancy
Fifth or >5 Pregnancies
Have you had any of the following *
Miscarriage
Emergency Caesarean Section
Stillborn baby
Assistance to concieve e.g. IVF, IUI, Clomid or other fertility drugs etc.
Assistance to concieve but not managed by a medical doctor e.g. reflexology, accupuncture etc
None of the above
When is / was your Big scan.
If you have not had your scan yet, please let Adeline know if there are any issues or concerns after your scan. *
DD / MM / YYYY
Have all your tests so far been ok? e.g. blood tests etc. *
Yes, I will just have to return for routine tests
No, the following was of concern or I have to go back for another check that is not routine (State below)
How active were you before becoming pregnant. *
How active are you currently *
Have you any Pilates experience (incl attending classes, teaching or studying)? Please describe *
What other pregnancy specific classesTherapies are you planning or planning to attend. *
Have you been diagnosed with Low Back pain / SPD / Pelvic girdle dysfunction/ SIJ Dysfunction (Sacro-Iliac joint) on this or previous pregnancies *
This Pregnancy: SPD
This Pregnancy: PGD
This Pregnancy: SIJ issues
This Pregnancy: Round Pelvic Pain
This Pregnancy: more than the normal pregnancy low back pain
Previous Pregnancy: SPD
Previous Pregnancy: PGP
Previous Pregnancy: SIJ issue
Previous Pregnancy: Round Pelvic pain
Previous Pregnancy: more than the normal pregnancy low back pain
No issues on this or previous pregnancies
Other
Occupation *
Does your occupation involves manual handling or anything else that may be a risk to your pregnancy? *
Have you any medical or surgical history that is relevant or have you been on medication in the past that is relevant.
Assistance to conceive medication does not need to be included. *

Do you have any of the following?

Any cardiac (heart) or respiratory (breathing difficulties now or in the past.
Any Kidney or liver problems
Incontinence (bladder or bowel)
Contagious diseases
Skin sensitivity to chlorine or contagious skin conditions
Uncontrolled vertigo or epilepsy

If you answered yes to any of the questions above, can you give some further information please.
Do you suffer from back/joint pain/slipped/bulging discs now/in the past?
Have you ever had scans on your back/joints?
Have you seen a medical specialist/consultant regards your pain? *
Have you any Medical legal cases ongoing e.g. after car accident/fall etc *
Yes
No
I have read the pool information document and I understand that i am encouraged to discuss attending the classes with my doctor if I have any concerns. *
Any other information that Adeline might need to know about.
I understand that I should not attend if I have
-Tummy upset including diarrhoea and vomiting
-Any contagious skin conditions (e.g. Herpes, plantar warts)
-Any illness that could be easily passed to another mother to be e.g. viral bug, mumps, chicken pox or similar.
-Any illness that may put another mother at risk

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