Prenatal Registration Form Name * First Name Last Name Date of Birth * MM DD YYYY Occupation Referred By Baby's Due Date * Gestation (weeks) * Medical Consultant * Phone Number * Hospital Is this your first pregnancy? If no, please provide further information, including miscarriages, still births, c-section details etc. MEDICAL & PREGNANCY CONDITIONS Heart Disease Diabetes Multiple pregnancy High / low blood pressure Asthma Placenta praevia Kidney disease Epilepsy Thyroid disease Vaginal bleeding Pre Eclampsia Poor foetal growth Breech presentation Other: Are you on any medication or vitamins? GENERAL DISCOMFORTS Headaches Arm or leg pain Heart burn / reflux Dizziness Pelvic joint pain Lower back pain Wrist or thumb pain Knee pain Sensory changes Varicosities Rib pain FITNESS HISTORY Were you exercising prior to this pregnancy? If yes, what type of exercise? Are you currently exercising? If yes, what type of exercise? PELVIC FLOOR Are you experiencing or have you experienced any of the following problems? I need to rush to the toilet I go very frequently to the toilet (more than 8 times per day) Sometimes I leak on the way to the toilet I experience leakage if I cough, sneeze or laugh I experience leakage if I exercise I have difficulty starting urination I have a weak stream with urination I have difficulty completely emptying my bladder I have had recurrent urinary tract infections I have experienced constipation I feel I have to strain on the toilet I feel like I don’t completely empty my bowels I have felt heaviness, dragging or building from my vagina I have discomfort with sexual intercourse Submitted By * Date * MM DD YYYY Thanks for completing the New Patient Form!
