PHYSICAL ACTIVITY SCREENING TOOLFOR EXERCISE DURING PREGNANCY First Name Last Name Email * Phone (###) ### #### 1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? Yes No 2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? Yes No 3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise? Yes No 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? Yes No 5. If you have diabetes (type I or type 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? Yes No 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? Yes No 7. Do you have any other conditions that may require special consideration for you to exercise? Yes No IF YOU ANSWERED YES to any of the 7 questions above, you should seek guidance from a health professional before participating in any further physical activity/exercise. Have you ever been told that you have any of the following (select all that are appropriate): IF YOU TICK YES to any of the 18 questions below, you should discuss opportunities to modify your physical activity/exercise with a health professional before participating in any further physical activity/exercise. It is still important that you avoid sitting for long periods of time. Incompetent cervix Ruptured membranes, premature labour 2 Persistant second or third trimester bleeding Placenta previa Pre-eclampsia Evidence of intrauterine growth restriction Multiple gestation (eg: triplets or higher number) Poorly controlled Type I diabetes, hypertension or thyroid disease Other serious cardiovascular, respiratory or systemic disorder History of spontaneous miscarriage, premature labour or fetal growth restriction Mild/moderate cardiovascular or chronic respiratory disease Pregnancy-induced hypertension Poorly controlled seizure disorder Type 1 diabetes Symptomatic anaemia Malnutrition, significantly underweight or eating disorder Twin pregnancy after the 28th week Other significant medical condition/s (Please detail below) Thank you!
