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Pre-Natal Health Screen Form

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.

PRE- NATAL HEALTH SCREEN

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