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Post-Natal Health Screen Form

If you have recently given birth please complete this form before participating in a class. (You DO NOT need to complete the general health screen as well).

Date of Birth
Day
Month
Year

GENERAL HEALTH SCREEN

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
Have you had an asthma attack REQUIRING IMMEDIATE MEDICAL ATTENTION at any time over the last 12 months?
If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
Do you have any other conditions that may require special consideration for you to exercise?

IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

POST- NATAL HEALTH SCREEN

Have you been checked by a GP yet? (regarding the recent birth)
Yes
No
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