PRE-EXERCISE CHECKLIST

  1. Have you ever had a miscarriage?
  2. In the past have you ever had pregnancy complications?
  3. How many previous pregnancies have you had?
  4. How many children live at home with you?

STATUS OF CURRENT PREGNANCY

Do you or have you suffered from:

  1. Marked fatigue 
  2. Bleeding from the vagina (spotting) 
  3. Unexplained faintness or dizziness 
  4. Unexplained abdominal pain 
  5. Sudden swelling, pain or redness in the calf of one leg 
  6. Persistent headaches or problems with headaches 
  7. Sudden swelling of ankles, hands or face 
  8. Absence of foetal movements after sixth month (if applicable)
  9. Failure to gain weight after fifth month (if applicable)

If you have answered YES to any of the above questions, please give details:

ACTIVITY HABITS DURING THE LAST MONTH

List only regular fitness/recreational activities:

Does your regular occupation (job/home) activity involve:

  1. Heavy lifting 
  2. Frequent walking/stair climbing 
  3. Occasional walking (once an hour) 
  4. Prolonged standing 
  5. Mainly sitting 

Do you currently smoke tobacco? 

Do you currently consume alcohol? 

NOTE: pregnant women are strongly advised not to smoke or consume alcohol during pregnancy and during lactation

ACTIVITY HABITS BEFORE BECOMING PREGNANT

List only regular fitness/recreational activities:

PHYSICAL ACTIVITY INTENTIONS

What physical activity do you intend to do?

CONTRAINDICATIONS TO EXERCISE: Please check with your Health Care Professional/ Midwife.

Absolute contraindications (Please state if any of the following are present)

  1. Ruptured membranes, premature labour 
  2. Persistent second or third trimester bleeding/placenta previa 
  3. Pregnancy-induced hypertension or pre-eclampsia 
  4. Incompetent cervix 
  5. Multiple pregnancy at risk of preterm delivery 
  6. Cardiac disease or restrictive lung disease 

Relative contraindications (Please state if any of the following are present)

  1. History of spontaneous abortion or premature labour in previous pregnancies
  2. Mild/moderate cardiovascular or respiratory disease (eg, chronic bronchitis, asthma)
  3. Severe anaemia
  4. Extreme low or high BMI 
  5. Poorly controlled type1 diabetes, thyroid disease, seizure disorder or hypertension  

NOTE: risk may exceed benefits of regular physical activity. The decision to be physically active or not should be made with qualified medical advice.

Physical activity recommendation

Recommended/approved:                                                                  Contraindicated:

I, _________________________, have discussed my plans to participate in physical activity during

my current pregnancy with my health care provider and I have obtained his/her approval to begin participation.