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Pilates
Women's Health Physiotherapy
Baby Massage
Live Well Waterford
Personal and professional, physiotherapist-led classes and treatments for both you and your baby
Pregnancy Screening Evaluation
Pregnancy Screening Evaluation
For clients attending private 1:1 pregnancy screening consultation
Session
*
Please Select....
Private 1:1 Physiotherapy Client
Pilates Class Participant
General Client Details
Name
*
Date of Birth
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
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Kiribati
North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
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Liberia
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Lithuania
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Mobile Number
*
Email
*
GP Name and Address
*
Obstetrician Name and Address
*
Allocated Midwifes Name and Address (if known)
Estimated Date of Delivery
*
Were you referred by a medical/health professional?
*
Please select...
Yes
No
Details of Health Professional:
Where did you hear about Live Well Waterford:
*
Medical Questionnaire
Are you currently experiencing OR ever been diagnosed with any of the following conditions?
*
Lower Back Pain
Pregnancy Related Pelvic Girdle Pain
Any other Spinal Condition
Any muscle or joint conditions
High or low Blood pressure
Circulatory Problems e.g clots
Type 1 or Type 2 Diabetes
Abnormal vaginal bleeding
Pre-eclampsia
Incompetent Cervix
History of spontaneous miscarriage
Anaemia
Epilepsy (Grand mal seizures)
Abnormal placental function/position
Serious heart, respiratory, renal or thyroid disease
NONE OF THE ABOVE
Is this your first pregnancy?
*
Please select...
Yes
No
If no, how many other children do you have and what are their ages?
Please note the AGE of each of your other children. Please also note the mode of delivery (vaginal or section) for each child, the weight at birth of each child, and report any previous obstetric injuries (tear/episiotomy) or any complications related to each delivery and pregnancy.
Did you have any complications with your previous pregnancy/pregnancies?
*
How many weeks pregnant are you?
*
Have you had any complications with your pregnancy?
*
Please select...
Yes
No
If yes, please specify
*
Are you expecting a multiple birth?
*
Please select...
Yes
No
Are you currently experiencing pelvic girdle pain or spinal or hip pain?
*
Please select...
Yes
No
If yes, please explain:
Please describe where your pain complaints are. Be as accurate as possible, noting down whether the pain is sharp and shooting or dull, achy and muscular in nature. When did the pain start?
Is your condition getting worse?
*
Please select...
Yes
No
Not Applicable
What activities aggravate your condition?
*
What activities help your condition?
*
Outline easing factors such as rest, ice, heat, certain positions, other therapies etc. Anything that has helped.
Is there a daily pattern to your condition?
*
Are you best in the morning? Worst in the morning? Do things settle down with movement or get worse with movement? Please be as accurate as possible.
Did you exercise before pregnancy?
*
Please select...
Yes
No
If yes, briefly outline please:
*
Have you been exercising during this pregnancy?
*
Please select...
Yes
No
If yes, please provide details:
*
Which, if any, of the following conditions have you been diagnosed with or had treatment for:
*
Asthma
Arthritis
Stroke
Cancer
Bronchitis
Depression
ME
Osteoporosis
Other
NONE OF THE ABOVE
If other, please state:
*
Current Health Status
Why have you decided to attend this LiveWell Pregnancy Service?
*
What short and long term goals do have have from coming to this clinic?
*
Please use this box if you feel there is any other information you would like to share with us prior to your appointment:
Thank you for taking the time to complete this form!
We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation. We rely on your feedback to help us improve our services. Your input is greatly appreciated.