SMART BUMPS MEDICAL HISTORY FORM

Nameyour full name

GP or Obstetrician Name and Location

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Are you currently pregnant?

YesNo

If so, how many weeks gestation?

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Are there any complicating factors to your pregnancy, or anything you would like us to know about?

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How many pregnancies have you had?

How many children have you had?

Birthing details of each child. Includes type of birth; vaginal delivery with/without any assistance, or C-section (planned or emergency), as well as any tearing or post birth complications for you (or the baby). Feel free to give as much detail as you like.more details

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Medical History and general health

Do you have any pain or restriction? (This can be related, or unrelated, to your pregnancy

YesNo

If so where?Please describe

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If yes, do you know what caused your problem?

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Has this occurred before, and if so, when?

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Is the problem improving?

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Are your symptoms worse during the day or at night?

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Describe what aggravates / relieves your problem

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Are you currently seeing any other Health Care professionals, and if so, who, and what management are they providing?

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Please give details of your Past Medical History (incl. accidents, trauma, cancer, any surgeries and general health information)

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Briefly describe how you feel your abdominal muscles and pelvic floor are currently.

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Do you experience any Stress Urinary Incontinence? (i.e. leakage with sneezing, coughing, laughing, running or jumping)

YesNo

Do you experience any Urge Urinary Incontinence? (i.e. leakage when you “need to go”)

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Please give an outline of your current exercise, as well as any prior Pilates/core based exercise

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Please outline any goals you wish to achieve

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Thank you for completing this form.