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Mamasterk Intake
Prenatal Questionnaire
This questionnaire is designed to help me learn what I need to know to help you stay safe and healthy during pregnancy while reaching your goals. Please take your time and fill out this questionnaire as honestly as possible.
Contact information
Name
(Required)
Pronouns
(Required)
She/her/hers
He/him/his
They/them/their
Other (if you're comfortable, specify in the last question of the form!)
Date of birth
(Required)
DD slash MM slash YYYY
Phone number
(Required)
Email
(Required)
Instagram handle
Occupation
Emergency contact name
(Required)
Emergency phone number
(Required)
Medical history & Pregnancy Details
Which trimester are you currently in? (please check one)
First Trimester (1-13 weeks)
Second Trimester (14-27 weeks)
Third Trimester (28-40 weeks)
What is your estimated due date?
(Required)
Has your doctor or midwife recommended any limitations for your exercise during pregnancy? If so, what are they?
(Required)
How are you feeling so far during this pregnancy? Are you experiencing any symptoms you think might impact your training?
(Required)
Have you had any past pregnancies or births? If so, how many, when, and how did you deliver?
(Required)
Is there anything else you’d like me to know about this pregnancy, or any past pregnancies?
(Required)
Are you currently taking any medications or health supplements? If you’re comfortable, please specify type, dosage, and reason for taking.
(Required)
Do you have a (family) history of heart trouble, high blood pressure, asthma or diabetes?
(Required)
Have you been hospitalized for any reason? If so, please explain.
(Required)
Do you have any other medical conditions that have not been mentioned so far that are relevant to your fitness journey?
(Required)
Health & Fitness
How is your mental wellbeing through this pregnancy?
(Required)
How would you describe your overall physical health?
(Required)
How would you describe your daily activity level (intense/moderate/sedentary)? Why?
(Required)
What degree of stress are you under on a scale of 1-10 (10 is highly stressed)? Why?
(Required)
Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.
(Required)
How often do you currently take part in physical exercise?
(Required)
If your participation in exercise is lower than you would like it to be, why is that?
(Required)
What was your activity level prior to being pregnant?
(Required)
Have you ever played any sports before? Which ones and for how long?
(Required)
Developing your program
In general, what are your goals for training during pregnancy?
(Required)
I'd like my program to focus on...
Maintaining or improving strength
Maintaining or improving aerobic capacity
Improving core and pelvic floor connection
Improving stress level or mental health
Building postpartum training skills
Having fun
What do you feel are the obstacles that could challenge your journey to your pregnancy training goals?
(Required)
If you achieved these goals, how would you feel?
(Required)
What are your favourite fitness activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)
(Required)
What are your LEAST favourite fitness activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)
(Required)
Realistically, how often would you like to exercise together?
(Required)
What are the best days/times during the week for you to commit to your program?
(Required)
Our coaching relationship
What drove you to seek out coaching during pregnancy?
(Required)
Describe your ideal coaching relationship? What is my role in your fitness journey?
(Required)
How can I help you reach the goals you listed?
(Required)
Anything else you’d like me to know about you? Personality? Needs? Core values? Anything that would help me get a better sense of YOU is totally encouraged here...go wild!
(Required)
Acknowledgment, participant release & cancelation policy
Consent
By checking the boxes below, I acknowledge and agree to the terms as stated below.
Consent
I have read, understood to my full satisfaction, and completed this questionnaire.
Consent
I understand and agree that it is my responsibility to inform Fit With Lou of any condition or changes in my health that might affect my ability to complete the program safely.
Consent
I agree that Fit With Lou shall not be liable or responsible for any injuries to me resulting from my participation and I expressly release and discharge Fit With Lou from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.
Consent
I understand that Fit With Lou operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. Where less than 24 hours notice is given, I understand that rescheduling will not be possible. My coach will utilize that time to further develop my program.
Consent
I agree to an initial 3-month commitment to coaching with Fit With Lou. After three months, I understand my contract will automatically renew on a month-to-month basis. I agree to give notice of 1 calendar month via email to hello@withlou.com in order to cancel the contract. I acknowledge that there are no refunds available on this investment.
Comments
This field is for validation purposes and should be left unchanged.