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Birthday
Day
Month
Year

Physical activity during pregnancy has many health benefits and is generally not risky for you and your baby. But for some conditions, physical activity is not recommended. This questionnaire is to help decide whether you should speak to your Obstetric Health Care Provider (e.g., your physician or midwife) before you begin or continue to be physically active.

In this pregnancy, do you have:

Mild, moderate or severe respiratory or cardiovascular diseases (e.g., chronic bronchitis)?
Yes
No
Epilepsy that is not stable?
Yes
No
Type 1 diabetes that is not stable or your blood sugar is outside of target ranges?
Yes
No
Thyroid disease that is not stable or your thyroid function is outside of target ranges?
Yes
No
An eating disorder(s) or malnutrition?
Yes
No
Twins (28 weeks pregnant or later)? Or are you expecting triplets or higher multiple births?
Yes
No
Low red blood cell number (anemia) with high levels of fatigue and/or light-headedness?
Yes
No
High blood pressure (preeclampsia, gestational hypertension, or chronic hypertension that is not stable)?
Yes
No
A baby that is growing slowly (intrauterine growth restriction)?
Yes
No
Unexplained bleeding, ruptured membranes or labour before 37 weeks?
Yes
No
A placenta that is partially or completely covering the cervix (placenta previa)?
Yes
No
Weak cervical tissue (incompetent cervix)?
Yes
No
A stitch or tape to reinforce your cervix (cerclage)?
Yes
No

In previous pregnancies, have you had:

Recurrent miscarriages (loss of your baby before 20 weeks gestation two or more times)?
Yes
No
Early delivery (before 37 weeks gestation)?
Yes
No
Do you have any other medical condition that may affect your ability to be physically active during pregnancy? What is the condition? Specify:
Yes
No
Specify

please give more information

Is there any other reason you are concerned about physical activity during pregnancy?
Yes
No
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