CLIENT DETAILS *

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Last Name

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Address 2

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State/Province

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GP/SPECIALIST DETAILS *

First Name

Last Name

Address *

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Address 2

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ABSOLUTE CONTRAINDICATIONS TO EXERCISE

Please inform us if the client has/develops any of the following absolute indications to exercise during their pregnancy

Ruptured membranes

Preterm labour

High Blood Pressure disorders of pregnancy

Incompetent cervix

Growth restricted foetus

Placenta Previa after 26 weeks

Tripplets or more

Persistent 2nd or 3rd Trimester bleeding

Uncontrolled Diabetes Type 1

Thyroid disease

Any other serious Cardiovascular disease, respiratory or systemic disorder

RELATIVE CONTRAINDICATIONS

Please inform us if the client has / develops any of the following relative contraindications to exercise during their pregnancy

Previous miscarriages / previous preterm birth

Mild / Moderate cardiovascular disorder

Mild / Moderate respiratory disorder

Anaemia (HB <100g/L)

Malnutrition or eating disorder

Twin pregnancy >28 weeks

Other significant medical condition

WARNING SIGNS

Please advise if experiencing any of the following warning signs below. Exercise should cease immediately until further clearance by medical professional.

Vaginal bleeding

Chest pain

Dyspnoea before exertion

Muscle weakness

Dizziness

Calf pain or swelling / DVT

Unexplained/new onset headache

Onset of labour

Decreased foetal movement