Surveypoint

Q1

Given Name

Name

Q2

Surname

Name

Q3

Gender

Female

Male

Other

Prefer not to say

Q4

Date of Birth

Q5

Address

Q6

Town

Q7

Postcode

Q8

Mobile number

Q9

E mail Address

Q10

Emergency contact person name

Q11

Mobile number

Q12

How did you hear about Kangatraining?

Health Professional

Kangatraining Aus Facebook

Referral

Facebook

Google

Instagram

Other

Q13

1. Are you currently pregnant? (If pregnant, you can only participate in Pre-Kanga)

Yes

No

Q14

2. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

No

Q15

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Yes

No

Q16

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? If so, have you got a current action management plan?

Yes

No

Q17

5. Do you have diabetes (type one or type two)? If yes, have you had trouble controlling your blood glucose in the last three months?

Yes

No

Q18

6. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

Yes

No

Q19

Baby/Child's name attending Kangatraining

Q20

Date of birth

Q21

What was your most recent type of birth?

Vaginal

Caesarean

Assisted

Q22

Date of your postnatal check-up (6 week for vaginal, 12 weeks for caesarean)

Q23

Were you cleared to begin physical exercise at that appointment or by a women’s health physiotherapist?

Q24

Can you briefly detail your previous and current exercise activities:

Q25

Are you breastfeeding?

Yes

no

Q26

Are you taking any medication? If so, for what condition?

Q27

Please tick if you suffer, or have suffered, from any of the following conditions

Symphysis Pubis Dysfunction pain in the central pubic area

Carpal Tunnel Syndrome (wrist/finger/hand/ forearm including pain and/or numbness and/or tingling)

Gestational diabetes.

Upper back/neck/shoulder pain

Piles/Haemorrhoids or constipation.

Varicose Veins.

Muscle Pain

Sacrum or sacroiliac joint pain pain in the low mid back/top of the buttocks

Knee pain side, front or back

Coccyx damage or pain

Prolapse (uterine, bladder, rectum, vagina)

Episiotomy cut, painful Perineum or tear

Caesarean wound discomfort or ongoing numbness

Buttocks/sciatica/ Piriformis pain.

Bleeding during or after exercise.

Separation of your abdominal muscles

Breast health/mastitis within the last 3 months.

Nerve damage sustained from birth Pudendal

Anaemia or taking iron medication.

Q28

If you suffer upper back/neck/shoulder pain give details

Q29

If you suffer joint pain, give details

Q30

If you suffer muscle pain give details

Q31

If you had/have an episiotomy cut, painful Perineum or tear, give the degree if known

Q32

Do you have Incontinence (urinary or faecal)? Tick all that apply

Yes

No

Do you leak when you cough, sneeze or need to urinate?

Do you feel any vaginal heaviness/dragging/bulging?

Have you seen a medical professional for these symptoms?

Q33

Have you been told you have any of the following conditions (please tick if it applies). If you tick any of the above conditions, it is recommended you seek guidance from an appropriate allied health professional prior to undertaking physical activity/exercise.

High blood pressure.

High cholesterol.

High blood sugar levels.

You have spent time in hospital (including day admission) for any medical condition/ illness/ injury in the past 12 months

Any muscle, bone or joint pain or soreness that made worse by particular types of activity

Q34

If you have spent time in hospital in the past 12 months, please detail

Q35

Does your baby have any medical conditions your Kangatrainer should be aware of? If so, please detail

Q36

Does your baby suffer from Hip Dysplasia?

Yes

no

Q37

Does your baby have any contraindications to being in a baby carrier (for example, lack of head control or neurological issues)?

Q38

Do you own a baby carrier? If yes, what type?

Q39

Have you experienced any problems using a baby carrier? If so, please detail

Q40

Is there anything else you believe your Kangatrainer should be aware of?

Q41

Name (printed)

Q42

Signature

Q43

Kangatraining Australia -Form Fill

Given Name

Surname

Gender

Date of Birth

Address

Town

Postcode

Mobile number

E mail Address

Emergency contact person name

Mobile number

How did you hear about Kangatraining?

1. Are you currently pregnant? (If pregnant, you can only participate in Pre-Kanga)

2. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? If so, have you got a current action management plan?

5. Do you have diabetes (type one or type two)? If yes, have you had trouble controlling your blood glucose in the last three months?

6. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

Baby/Child's name attending Kangatraining

Date of birth

What was your most recent type of birth?

Date of your postnatal check-up (6 week for vaginal, 12 weeks for caesarean)

Were you cleared to begin physical exercise at that appointment or by a women’s health physiotherapist?

Can you briefly detail your previous and current exercise activities:

Are you breastfeeding?

Are you taking any medication? If so, for what condition?

Please tick if you suffer, or have suffered, from any of the following conditions

If you suffer upper back/neck/shoulder pain give details

If you suffer joint pain, give details

If you suffer muscle pain give details

If you had/have an episiotomy cut, painful Perineum or tear, give the degree if known

Do you have Incontinence (urinary or faecal)? Tick all that apply

Have you been told you have any of the following conditions (please tick if it applies). If you tick any of the above conditions, it is recommended you seek guidance from an appropriate allied health professional prior to undertaking physical activity/exercise.

If you have spent time in hospital in the past 12 months, please detail

Does your baby have any medical conditions your Kangatrainer should be aware of? If so, please detail

Does your baby suffer from Hip Dysplasia?

Does your baby have any contraindications to being in a baby carrier (for example, lack of head control or neurological issues)?

Do you own a baby carrier? If yes, what type?

Have you experienced any problems using a baby carrier? If so, please detail

Is there anything else you believe your Kangatrainer should be aware of?

Name (printed)

Signature

Date