Post-natal Questionnaire- Complete Physio Clinics London

Full Name*

First Last

Did you experience any pregnancy related health conditions?*

Yes
No

If so what?

Did you participate in any training whilst pregnant and if so how often and what kind?*

How long was your most recent labour?*

Where did you deliver your baby?*

Have you had your 6 week check? Were there any complications? Did you have a full check up including internally?*

Are you still under the care of a Consultant and if so why?*

Are you breastfeeding?*

Yes
No

Are you still bleeding?*

Yes
No

Do you ever experience leakage of urine and/ or stool?*

Yes
No

Do you ever feel urgency from the bladder and/ or bowel?*

Yes
No

Do you suffer from constipation or regularly strain on the toilet?*

Yes
No

Do you have any difficulties emptying from the bladder or bowel?*

Yes
No

Do you have any difficulty controlling wind?*

Yes
No

Do you experience a sensation of pressure or heaviness in your vagina or rectum or ever noticed a bulge inside?*

Yes
No

Do you experience pain in your vulva or vagina with or without sex?*

Yes
No

Please give details of your delivery and any previous deliveries

Child 1: Date Born

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of heaviest baby

Do you have any other children?

Yes
No

Child 2: Date Born

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby

Do you have any other children?

Yes
No

Child 3: Date Born

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby

Do you have any other children?

Yes
No

Child 4: Date Born

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby