Postpartum Personal Training | KaylaFit

Postpartum New Client Intake Form

Fill Out The Form Below:

Full Name:

Email:

Phone:

Address:

Emergency Contact (name, relation, phone number) :

Do you have medical clearance to exercise? (Required to begin training)

OB/GYN or Midwife’s Name:

Their Contact Info:

Date:

Age:

# weeks/mo/yrs postpartum:

Date Gave Birth:

# Pregnancy (1st, 2nd, etc.)

Baby’s (babies) name(s)

Names/ages of other children (if applicable):

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Pregnancy & Birth Experience

Describe how your most recent pregnancy experience felt physically (i.e. smooth, difficult). Did you experience pains, injuries, or complications?

Where did you give birth (hospital, home birth, etc.)?

Did you have a vaginal or cesarean delivery? If vaginal, were there any interventions used (forceps, vacuum assistance, episiotomy, etc.)? If cesarean, was it planned or unplanned?

Did you experience any vaginal tearing or other complications? If so, please describe.

Overall, how would you describe your birth experience in terms of difficulty (i.e. “relatively” easy, difficult)? How did it compare with your expectations?

Have you done any other recovery work (i.e. physical therapy, online program, etc)? If so, please describe.

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Postpartum Experience

Do you experience accidental urine leakage during sudden movements (coughing, laughing, sneezing) or during exercise? If so, do you know when this started and what activities it tends to occur with?

Did your medical provider check you for pelvic organ prolapse? If not, do you ever have a heavy “bowling ball” feeling between your legs?

Did your medical provider check you for diastasis recti? If so, did your doctor say you have it, and to what degree?

Did your medical provider give you any restrictions or guidance at your postpartum check-up?

Overall, how are you feeling physically now?

Are you nursing? Pumping?

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Medical History

Do you have any other (non-pregnancy related) pains, injuries, or medical conditions?

Have you ever had a major surgery or injury? If so, does it still impact you today?

Do you currently take any medications (OTC or prescription)? If so, what are they and what are they for?

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Activity History

Please describe your pre-pregnancy physical activity or exercise routine (# days/wk, intensity, exercise type, etc.).

Please describe your pregnancy physical activity or exercise routine (# days/wk, intensity, exercise type, etc.).

If relevant, describe your postpartum physical activity or exercise routine (# days/wk, intensity, exercise type, etc.).

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Lifestyle

What is your occupation? Are you on maternity leave? If so, when do you plan to return (if at all)?

Approximately how many hours would you say you spend sitting each day?

How are you feeling mentally?

What is your current sleep pattern? How many hours are you getting at night and (if relevant) daytime naps?

What is your current stress level on a scale of 1 (no stress) to 10 (severe stress)? What are your primary sources of stress?

What is your support system like (spouse, partner, family, friends, support group, etc.)?

Do you have any favorite hobbies or activities you like to do?

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Nutrition

How much water would you say you drink per day?

What other fluids do you typically consume per day (coffee, tea, soda, etc.) and how much?

Are you taking a prenatal vitamin?

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Goals

What are your specific goals for this training program? If multiple, rank in priority order.

Do you have a desired timeframe for achieving these goals?

How many days per week can you commit to doing personal training?

Outside of your training days, can you commit to doing other physical activity (i.e. walking, elliptical, etc)? If so, what types of movement/cardio activities do you like doing?

Anything you’d like me to know as your coach (i.e. what motivates you, what doesn’t)?

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Postpartum New Client Intake Form

Fill Out The Form Below:

Contact Details

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