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10:15 PM

Tuesday 18 August

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Empower Your Pregnancy — Pre-Exercise Screening

Postpartum / Perinatal — Pre-Exercise Screening

Strong Starts Perinatal — Pre-Exercise Screening

PT Client (Male) — Basic Information & Screening

PT Client (Female) — Basic Information & Screening

Liability Waiver & Acknowledgement

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Empower Your Pregnancy — Pre-Exercise Screening

Please take the time to fill out the below form to the best of your ability. The more details you provide, the better I am able to support you. If you wish to discuss anything that comes up, do not hesitate to message me or ask in the first session. If there is a question you are uncomfortable answering, you can leave it blank. Please note this form is confidential and won't be shared with anyone without your permission.

Your details

Name

Age

Occupation

Email address

name@email.com

Emergency Contact — name and number

Medical background

Have you received clearance from a doctor to be involved in an exercise program?

Have you ever been diagnosed by a doctor or experienced any of the following?

Heart condition

Stroke

Chest pains during exercise

Felt faint or had dizzy spells when exercising

An asthma attack requiring medical attention in the last 12 months

Bone, muscle or joint problems that you have been advised may be made worse with exercise

Any other medical condition that could be dangerous for you to participate in physical activity

Have you been diagnosed with any of the following?

Low or High Blood Pressure

Low or High Blood Sugar

High Cholesterol

Type 1, Type 2 or Gestational Diabetes

If you answered yes to any of the above, please provide detail

Are you working with any health practitioners? If yes, what is their name and do you give permission for me to contact them if required?

Pregnancy details

Estimated due date

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

Pregnancy care provider

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

For any previous births, please share any details you believe relevant

Exercise history and goals

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

What are your goals / reasons for training throughout your pregnancy?

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

Is there anything particular you wish to learn / work with me on?

Any other details you wish to share?

Pelvic floor screening

Answering the following is optional, however the more information you provide, the better I can help keep you safe and pain/complication free.

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

If you are currently seeing a Women's Health Physio, what is their name and do you consent to me making contact with them?

Do any of the following apply?

I have noticed a bulging from front or back passage, or am aware I have a prolapse

I experience heaviness or a 'dragging' sensation in my pelvic floor

I experience leaking with activity, laughing, coughing, sneezing etc.

I feel pain during sex or upon insertion

I experience constipation or have difficulty emptying bowels

I experience urge incontinence and/or need to go to the toilet quickly

Have you been assessed for Diastasis Recti (abdominal separation)? If so, when and what was the result?

Permissions

How did you hear about us?

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

This is a read-only sample. Change the “Form” above to preview a different one.

How did you hear about us?

10 responses total

Instagram 4

— (blank) 2

Know katur 2

Advertisement 1

Saw an ad in the park 1

All submissions (10)

Fiona Chan 14 Aug 2026

Name

Fiona

Age

Occupation

Barista

Email address

fionachan93@gmail.com

Emergency Contact — name and number

0458312550

Have you received clearance from a doctor to be involved in an exercise program?

Estimated due date

13/12

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

Yes

Pregnancy care provider

RHH

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

I was born with G6PD, so they categorise me as a high risk person. But it doesn’t affect my day to day life.

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

Fatigue and back pain

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

For any previous births, please share any details you believe relevant

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Play sports

What are your goals / reasons for training throughout your pregnancy?

Ease my back pain and hoping for an easier birth.

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

Is there anything particular you wish to learn / work with me on?

Any other details you wish to share?

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

If you are currently seeing a Women's Health Physio, what is their name and do you consent to me making contact with them?

Do any of the following apply?

I experience urge incontinence and/or need to go to the toilet quickly

Have you been assessed for Diastasis Recti (abdominal separation)? If so, when and what was the result?

How did you hear about us?

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Madeleine 11 Aug 2026

Name

Madeleine Delany

Age

Occupation

Publishing/sales

Email address

madeleine.delany@gmail.com

Emergency Contact — name and number

Chance Wheeless 0497 497 752

Have you received clearance from a doctor to be involved in an exercise program?

Yes

Estimated due date

27 January 2027

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

Yes - first

Pregnancy care provider

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

Nausea/fatigue

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Sporadic floor Pilates classes, daily dog walking

What are your goals / reasons for training throughout your pregnancy?

To strengthen my lower back and supporting muscles To strengthen my pelvic floor Strengthen everywhere! Have an outlet for physical release and to get my body moving with purpose during this pregnancy and afterwards

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

L5-S1 disk surgery 2 yrs ago (herniated disk)

Is there anything particular you wish to learn / work with me on?

Pelvic floor, back, legs

Any other details you wish to share?

Looking forward to it!

How did you hear about us?

Instagram

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Madeleine 11 Aug 2026

Name

Madeleine Delany

Age

Occupation

Publishing/sales

Email address

madeleine.delany@gmail.com

Emergency Contact — name and number

Chance Wheeless 0497 497 752

Have you received clearance from a doctor to be involved in an exercise program?

Yes

Estimated due date

27 January 2027

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

Yes - first

Pregnancy care provider

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

Nausea/fatigue

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Sporadic floor Pilates classes, daily dog walking

What are your goals / reasons for training throughout your pregnancy?

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

L5-S1 disk surgery 2 yrs ago (herniated disk)

Is there anything particular you wish to learn / work with me on?

Pelvic floor, back, legs

Any other details you wish to share?

Looking forward to it!

How did you hear about us?

Instagram

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Leila 25 Jul 2026

Name

Leila Shahtahmasebi

Age

Occupation

Physiotherapist

Email address

leilass13@hotmail.com

Emergency Contact — name and number

Danial Neale 0473177780

Have you received clearance from a doctor to be involved in an exercise program?

No - but not needed

Estimated due date

23/01/27

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

1 child age 4 1 ectopic pregnancy in Jan 2026 This is my 3rd pregnancy

Pregnancy care provider

GP Dr Rose Provera

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

10/05/2022 delivered unplanned C-section Ectopic pregnancy ruptured left fallopian tube and surgery for removal of left tube Jan 2026

For any previous births, please share any details you believe relevant

Posterior facing birth 2022 - long labour, daughter was unable to turn, incredible back pain and spasms. Was trying for home birth and ended up in hospital on epidural and then C-section as dilation stopped at 8cm

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Played sports most of my life, prior to daughter regularly attended gym, yoga classes, played soccer In last six months have been doing weight training and walking/running sporadically

What are your goals / reasons for training throughout your pregnancy?

Want to stay fit and strong. Want to maintain flexibility for birth and to reduce pains during pregnancy Would like a vaginal birth this time round so anything to help for this

Is there anything particular you wish to learn / work with me on?

Improving hip/pelvic mobility and strength Maintain weight

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

How did you hear about us?

Saw an ad in the park

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

Beccy Bradshaw 17 Jul 2026

Name

Rebecca Bradshaw

Age

Occupation

Yoga teacher & nutrition coach

Email address

beccyyoga@gmail.com

Emergency Contact — name and number

Duri Bradshaw 0427345483

Have you received clearance from a doctor to be involved in an exercise program?

Are you working with any health practitioners? If yes, what is their name and do you give permission for me to contact them if required?

My physio Claire Shield at the physio stop

Estimated due date

21/11/26

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

No - 1 other child

Pregnancy care provider

Hobart OBGYN

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

Feb 2024 c section

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

Long labour ended in emergency c-section

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Yoga and Pilates and strength training

What are your goals / reasons for training throughout your pregnancy?

To stay healthy and strong

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

Have you been assessed for Diastasis Recti (abdominal separation)? If so, when and what was the result?

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

Ange Allen 11 Jul 2026

Name

Angela Allen

Age

Occupation

Mum & Business Manager & Owner

Email address

angela@allenbuilt.com.au

Emergency Contact — name and number

Shannon husband 0415583401

Have you received clearance from a doctor to be involved in an exercise program?

Are you working with any health practitioners? If yes, what is their name and do you give permission for me to contact them if required?

Maddy Males Dr Stephen Bradford Yes, as long as I am informed.

Estimated due date

26/08/2028

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

2 kids already

Pregnancy care provider

S Bradford

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

Nil

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

2018 c section 2021 vbac

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

Vbac 23 hrs labour from first contraction Episiotomy

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Katie knows :)

What are your goals / reasons for training throughout your pregnancy?

Stay fit and do a marathon Sydney marathon 2027 Aug.

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

Is there anything particular you wish to learn / work with me on?

Strength

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

Do any of the following apply?

I experience leaking with activity, laughing, coughing, sneezing etc.

How did you hear about us?

Know katur

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

Ange Allen 11 Jul 2026

Name

Angela Allen

Age

Occupation

Mum & Business Manager & Owner

Email address

angela@allenbuilt.com.au

Emergency Contact — name and number

Shannon husband 0415583401

Have you received clearance from a doctor to be involved in an exercise program?

Are you working with any health practitioners? If yes, what is their name and do you give permission for me to contact them if required?

Maddy Males Dr Stephen Bradford Yes, as long as I am informed.

Estimated due date

26/08/2028

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

2 kids already

Pregnancy care provider

S Bradford

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

Nil

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

2018 c section 2021 vbac

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

Vbac 23 hrs labour from first contraction Episiotomy

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Katie knows :)

What are your goals / reasons for training throughout your pregnancy?

Stay fit and do a marathon Sydney marathon 2027 Aug.

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

Is there anything particular you wish to learn / work with me on?

Strength

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

Do any of the following apply?

I experience leaking with activity, laughing, coughing, sneezing etc.

How did you hear about us?

Know katur

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

Claire Williams 6 Jul 2026

Name

Claire Williams

Age

Occupation

Acupuncturist

Email address

vegemite@acupuncturewithclaire.com

Emergency Contact — name and number

Joel 0419153679

Have you received clearance from a doctor to be involved in an exercise program?

Never needed to be under care

If you answered yes to any of the above, please provide detail

Non applicable

Are you working with any health practitioners? If yes, what is their name and do you give permission for me to contact them if required?

Not working with anyone.

Estimated due date

Oct 1

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

First pregnancy.

Pregnancy care provider

MGP program

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

No risks. Low risk pregnancy

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

No :)

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

No previous births or pregnancies of any kind :)

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

For any previous births, please share any details you believe relevant

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Yoga, hiking walking working too much haha (including massage)

What are your goals / reasons for training throughout your pregnancy?

Keep moving. Build strength where needed and prevent injuries

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

No issues :)

Is there anything particular you wish to learn / work with me on?

Nope :) just labour/ birth prep

Any other details you wish to share?

No :)

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

No :)

If you are currently seeing a Women's Health Physio, what is their name and do you consent to me making contact with them?

Have you been assessed for Diastasis Recti (abdominal separation)? If so, when and what was the result?

How did you hear about us?

Instagram

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

Claire Williams 6 Jul 2026

Name

Claire Williams

Age

Occupation

Acupuncturist

Email address

vegemite@acupuncturewithclaire.com

Emergency Contact — name and number

Joel 0419153679

Have you received clearance from a doctor to be involved in an exercise program?

Never needed to be under care

If you answered yes to any of the above, please provide detail

Non applicable

Are you working with any health practitioners? If yes, what is their name and do you give permission for me to contact them if required?

Not working with anyone.

Estimated due date

Oct 1

Is this your first pregnancy? If not, how many children/pregnancies? Provide details if you feel comfortable

First pregnancy.

Pregnancy care provider

MGP program

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

No risks. Low risk pregnancy

Are you experiencing any nausea, fatigue, pelvic pain or other symptoms that may affect your training?

No :)

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

No previous births or pregnancies of any kind :)

For your most recent birth, please provide any relevant information (length of labour, pushing phase, tears/episiotomy, assisted delivery, stitches, scar pain/sensation, etc.)

For any previous births, please share any details you believe relevant

What is your exercise history? What were you doing previously and what have you done in the last 6 months?

Yoga, hiking walking working too much haha (including massage)

What are your goals / reasons for training throughout your pregnancy?

Keep moving. Build strength where needed and prevent injuries

Do you have any concerns about exercising / anything important for me to know? (e.g. previous injuries, pain, fatigue, pelvic girdle pain)

No issues :)

Is there anything particular you wish to learn / work with me on?

Nope :) just labour/ birth prep

Any other details you wish to share?

No :)

Have you seen, or do you see, a Women's Health Physio? If yes, what did you go for and what was the result?

No :)

If you are currently seeing a Women's Health Physio, what is their name and do you consent to me making contact with them?

Have you been assessed for Diastasis Recti (abdominal separation)? If so, when and what was the result?

How did you hear about us?

Instagram

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes

Annie 30 Jun 2026

Name

Annie

Age

Occupation

Executive Assistant Manager

Email address

kerriannadavidson@gmail.com

Emergency Contact — name and number

Johnny Fox - 0437398373 (Husband)

Estimated due date

Sept 16

Pregnancy care provider

Royal Hobart Hospital

Has a doctor or care provider identified any risk factors or areas of concern in your pregnancy? If yes, please provide details

High risk Preeclampsia

If you have had previous births, list DOB and type of birth (vaginal, planned c-section, unplanned c-section, D&C)

D&C

What are your goals / reasons for training throughout your pregnancy?

Strong and healthy, knowledge on how to strengthen and engage pelvic floor

Do any of the following apply?

I experience urge incontinence and/or need to go to the toilet quickly

Do you agree for photographs to be taken during sessions and used on social media for future promotional literature and/or course content?

Yes