Prenatal Exercise Screening Form
Please complete this form to help us understand your readiness and any precautions needed for prenatal exercise participation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Expected Due Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many weeks pregnant are you?
*
Have you participated in prenatal exercise before?
*
Yes
No
Do you have any current or past medical conditions that may affect exercise?
*
High blood pressure
Gestational diabetes
Pre-eclampsia
None of the above
Other
Are you currently experiencing any of the following symptoms?
*
Unusual shortness of breath
Dizziness or fainting
Vaginal bleeding
Severe abdominal pain
None of the above
Please describe your current physical activity or exercise habits.
*
Is there anything else you would like us to know before you participate in prenatal exercise?
Submit
Should be Empty: