Postpartum Health Questionnaire

Section 1

Your details

Full name

Date of birth

Contact number

Email

Address

Emergency contact name

Emergency contact number

Relationship to you

Section 2

Your birth and recovery

Date you gave birth

Type of birth

Postpartum check (the 6 to 8 week NHS check): date and outcome

Are you currently breastfeeding?

Yes No

How is your postpartum bleeding? Ongoing or stopped, with date if known

Have you recently had a coil or IUD fitted?

Yes No

Have you been cleared by your GP, midwife, health visitor or a women's health physiotherapist to return to exercise?

Yes No Not yet

Section 3

Pregnancy and postpartum history

Please share anything relevant about your pregnancy and birth, including complications, illnesses, or anyone you are currently seeing such as a physiotherapist, osteopath or chiropractor.

Section 4

Condition and symptom checklist

Please tick anything you currently have or have had. This is not here to worry you. It simply helps me build something that is genuinely appropriate for your body. If you tick anything, we will talk it through together.

Section 5

Health screening

Please answer Yes or No.

1.Do you have a breathing condition, such as asthma or bronchitis?

Yes No

2.Have you ever had chest pain?

Yes No

3.Are you currently taking any medication?

Yes No

4.Is there any other reason, physical or medical, why you should not take part in physical activity right now?

Yes No

Additional information

If you answered Yes to any of the above, please note medication, reason, or any detail you want me to know.

Section 6

Readiness and lifestyle

Fill in as much as you would like. These questions are optional but they help me tailor your training.

What did your training look like before and during pregnancy, and what does it look like now?

How are you feeling in your body since giving birth, and is there anything you would like to feel more confident with as you return to exercise?

What would getting back to yourself look like for you?

How are your sleep and energy at the moment? This helps me pitch your sessions realistically.

Which types of movement do you enjoy, and which would you rather avoid for now?

Do you have support around you, at home or at work?

Is there anything else, physically or emotionally, that you would like me to know as we start?

Informed consent

Informed consent

Signature (type your full name)

Date

I confirm the typed name above is my electronic signature, and that the information I have provided is accurate to the best of my knowledge.

Optional

Stay in touch

I would like to receive occasional news and updates from Thea Hudson. My details will never be shared with a third party.