Pregnancy screening form Name * First Name Last Name Email * How many weeks pregnant are you? Have you spoken to your doctor about exercising during pregnancy? Yes No What is your main reason for exercising? General fitness Social interaction Support for pregnancy/postpartum recovery First time exercising and want to start during pregnancy Other Are you currently experiencing any of the following? Pelvic pain (e.g., pubic bone, hips, or SI joint) Lower back pain Carpal tunnel symptoms (wrist pain, numbness, or tingling) Knee or ankle pain None of the above Other joint pain (If you develop any of these during exercise, please let your instructor know immediately.) Have you noticed any of the following changes? Urinary leakage (e.g., when sneezing, coughing, or exercising) Heaviness or pressure in the pelvic area None of the above (If you experience any of these, we may adjust your exercises for better comfort and support.) How many pregnancies have you had, including this one? First pregnancy Second pregnancy Third or more (Pregnancy history helps tailor exercise choices based on your body’s previous adaptations.) Have you done structured exercise before? Yes, regularly Occasionally No, this is my first time (It’s great to start exercising during pregnancy, even if you haven’t before! We’ll guide you safely.) Do you have any concerns or questions about exercising while pregnant? You do not need to disclose private medical conditions—this form focuses on exercise safety only. If you experience new pain or discomfort, please let your instructor know. Your instructor is here to support you, not to diagnose or treat medical issues. Thank you!
