Questionaire Pregnancy Yoga

Participant Details

Name *

+ Name of parent/guardian if applicable

Your Due Date *

Day

Month

Year

No. of weeks pregnant: *

Age *

Telephone No.

(Optional)

Email Address *

Pregnancy Information

Please answer YES or NO to each question to the best of your ability.

If your health changes as your pregnancy progresses you should fill in this questionnaire again.

In this pregnancy, do you have *

	Yes	No
a. Mild, moderate or severe respiratory or cardiovascular diseases (e.g., chronic bronchitis)?	a. Mild, moderate or severe respiratory or cardiovascular diseases (e.g., chronic bronchitis)? - Yes	a. Mild, moderate or severe respiratory or cardiovascular diseases (e.g., chronic bronchitis)? - No
b. Epilepsy that is not stable?	b. Epilepsy that is not stable? - Yes	b. Epilepsy that is not stable? - No
c. Type 1 diabetes that is not stable or your blood sugar is outside of target ranges?	c. Type 1 diabetes that is not stable or your blood sugar is outside of target ranges? - Yes	c. Type 1 diabetes that is not stable or your blood sugar is outside of target ranges? - No
d. Thyroid disease that is not stable or your thyroid function is outside of target ranges?	d. Thyroid disease that is not stable or your thyroid function is outside of target ranges? - Yes	d. Thyroid disease that is not stable or your thyroid function is outside of target ranges? - No
e. An eating disorder(s) or malnutrition?	e. An eating disorder(s) or malnutrition? - Yes	e. An eating disorder(s) or malnutrition? - No
f. Twins (28 weeks pregnant or later)? Or are you expecting triplets or higher multiple births?	f. Twins (28 weeks pregnant or later)? Or are you expecting triplets or higher multiple births? - Yes	f. Twins (28 weeks pregnant or later)? Or are you expecting triplets or higher multiple births? - No
g. Low red blood cell number (anemia) with high levels of fatigue and/or light-headedness?	g. Low red blood cell number (anemia) with high levels of fatigue and/or light-headedness? - Yes	g. Low red blood cell number (anemia) with high levels of fatigue and/or light-headedness? - No
h. High blood pressure (preeclampsia, gestational hypertension, or chronic hypertension that is not stable)?	h. High blood pressure (preeclampsia, gestational hypertension, or chronic hypertension that is not stable)? - Yes	h. High blood pressure (preeclampsia, gestational hypertension, or chronic hypertension that is not stable)? - No
i. A baby that is growing slowly (intrauterine growth restriction)?	i. A baby that is growing slowly (intrauterine growth restriction)? - Yes	i. A baby that is growing slowly (intrauterine growth restriction)? - No
j. Unexplained bleeding, ruptured membranes or labour before 37 weeks?	j. Unexplained bleeding, ruptured membranes or labour before 37 weeks? - Yes	j. Unexplained bleeding, ruptured membranes or labour before 37 weeks? - No
k. A placenta that is partially or completely covering the cervix (placenta previa)?	k. A placenta that is partially or completely covering the cervix (placenta previa)? - Yes	k. A placenta that is partially or completely covering the cervix (placenta previa)? - No
l. Weak cervical tissue (incompetent cervix)?	l. Weak cervical tissue (incompetent cervix)? - Yes	l. Weak cervical tissue (incompetent cervix)? - No
m. A stitch or tape to reinforce your cervix (cerclage)?	m. A stitch or tape to reinforce your cervix (cerclage)? - Yes	m. A stitch or tape to reinforce your cervix (cerclage)? - No

In previous pregnancies, have you had *

	Yes	No
a. Recurrent miscarriages (loss of your baby before 20 weeks gestation two or more times)?	a. Recurrent miscarriages (loss of your baby before 20 weeks gestation two or more times)? - Yes	a. Recurrent miscarriages (loss of your baby before 20 weeks gestation two or more times)? - No
b. Early delivery (before 37 weeks gestation)?	b. Early delivery (before 37 weeks gestation)? - Yes	b. Early delivery (before 37 weeks gestation)? - No

Do you have any other medical condition that may affect your ability to be physically active during pregnancy? *

Yes

What is the condition? Specify:

Is there any other reason you are concerned about physical activity during pregnancy?

General Advice for Being Physically Active During Pregnancy

Follow the guidance from the United Kingdom's Chief Medical Officers (2019) on the amount and type of physical activity pregnant women should be doing to improve their health: www.gov.uk/government/collections/physical-activity-guidelines

It is recommended that pregnant women accumulate 150 minutes of moderate-intensity physical activity throughout the week and perform strengthening activities twice per week. If you are planning to take part in vigorous-intensity physical activity, or be physically active at elevations above 2500 m (8200 feet), then consult with a healthcare professional beforehand. If at any time you have questions or concerns about being active during your pregnancy, seek advice from a healthcare professional.

Declaration

To the best of my knowledge, all of the information I have supplied on this questionnaire is correct. If my health changes, I will complete this questionnaire again.

I answered NO to all Pregnancy Information Questions

Confirm

Physical activity is recommended.

I answered YES to one or more Pregnancy Information Questions and I will speak with a healthcare professional before beginning or continuing physical activity.

Confirm

Healthcare Professional Consultation Form for Prenatal Physical Activity: UK Version can be used to start the conversation (www.csep.ca/getactivequestionnaire-pregnancy)

I have spoken with my healthcare professional who has recommended that I take part in physical activity during my pregnancy

Confirm

Leave this field blank

Antenatal

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