Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Have you had your 6 week check or 12 week check if you had a c-section? *

Yes

No

Do you have any health concerns that would stop you from exercising during pregnancy? *

Yes

No

Has your doctor ever said you have a heart condition and that you should only partake in physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you partake in physical activity? *

Yes

No

In the past month have you experienced a chest pain when you were NOT engaged in physical activity? *

Yes

No

Has your doctor ever recommended medication for your blood pressure or a heart condition? *

Yes

No

Do you have a bone or joint problem that could be or has been aggravated by physical activity? *

Yes

No

Do you tend to lose consciousness or fall over as a result of dizziness? *

Yes

No

Do you know of any other reason why you should not partake in physical activity? *

Yes

No

Have you had COVID-19?

Yes

No