Sample of a Pre-Participation Medical Screening form for prenatal exercise programs

 

 

Patients name_________________________________        Patients Address___________________________________

 

Date ________________     Age (yr)______       Phone ____________         ___________________________________

 

 

Part A:  (TO BE COMPLETED BY PARTICIPANT)

 

1.  Date of last physical examination:  ___________                2.  First day of last menstrual period: ___________________

3.  Estimated date of delivery: ________________                 4.  Is this your first pregnancy? (circle answer)  Yes   /   No 

5.  In earlier pregnancies, did you have any medical difficulties or complications?  Yes   /   No

    If yes, please describe these briefly below and ask your physician to describe them in Part B

 

_____________________________________________________________________________________________

 

6.  In your present pregnancy have you experience any of the following?  (please circle)

       

Vaginal Bleeding

Pain or swelling in the calf of a leg

Any gush of fluid from the vagina

Severe nausea or vomiting

Infection (cold, viral or bacterial infections)

Unexplained abdominal pain

Unusual fatigue or lack of energy

Sudden swelling of face, hands, or feet

Severe headaches

 

7.  Do you or have you in the past experienced any of the following?  (please circle)

 

Problems with your heart

Problems with your breathing

Pains or palpitations in your heart or chest

High blood pressure

Pains or problems with bones or joints

Diabetes

 

Other medical problems which might affect your ability to exercise:

 

_______________________________________________________________________________________________

 

8.  Please list any drugs or medications that you are currently taking:  ___________________________________________

 

9.  At the present time, do you smoke cigarettes?  (circle answer)      Yes   /   No

 

10.  At the present time, do you consume any alcohol?  (circle answer)      Yes   /   No

 

11.  At the present time, do you participate in any form of exercise?  (circle answer)

       

        REGULARLY     OCCASIONALLY     SELDOM     NEVER        Type of Exercise:  ________________________

 

 

Part B:  (TO BE COMPLETED BY PARTICIPANTS PERSONAL PHYSICIAN OR OBSTETRICIAN)

 

1.  To the Best of your knowledge, is the information provided in PART A by your patient complete and medically accurate?

(circle answer)   Yes   /   No

 

2.  Has your patient experienced any of the following specific medical symptoms or conditions in this pregnancy or in previous

 pregnancies which might suggest that participation in an exercise program is unusually risky or dangerous?  (circle applicable items)

 

Premature Labour

History of spontaneous abortion

Anemia

Incompetent cervix

Intrauterine growth retardation

Pre-eclampsia

Toxaemia

Infection or other systemic disorder

 

3.  Does your patient have any additional medical symptoms or conditions (e.g.  multiple pregnancy, diabetes, hypertension, heart disease, pulmonary disease, arthritis) which would make it inadvisable for her to participate in an exercise program during pregnancy?  (circle answer)      Yes   /   No  

If YES, please explain:   ________________________________________________________________________________

___________________________________________________________________________________________________

 

Part C:  Please check one of the following:

 

_______  The above-named person is in good general health and information currently available suggests that she can safely participate in

                 fitness and pregnancy classes conducted by a qualified instructor.

_______  The above-name person should not participate in fitness and pregnancy classes since medical risks may outweigh the expected

                benefits. 

 

Additional Comments:  ________________________________________________________________________________

 

Signed:  ________________________________________  MD address:  _______________________________________

 

Phone:  _________________________________

 

*NOTE:  If your patient's medical status changes during the course of her pregnancy, you are free to withdraw medical approval of her participation.  The instructor will inform you of any unusual symptoms observed in relation to exercise classes * 

 

References

Wolfe, L. et al.  (1989).  Prescription of aerobic exercise during pregnancy.  Sports Med,  8, 273.