In what week of pregnancy are you currently?

Are you over 36 years of age? - Select - Yes No

Is your pregnancy considered high-risk or normal? - Select - High-risk Normal

Have you ever experienced a miscarriage or pre-term labor? - Select - Yes No

Just prior to, or during your pregnancy, did you suffer any abdominal injury or surgery? - Select - Yes No

Have you noticed a reduction in fetal movement during the previous 24-hour period? - Select - Yes No

Have you had excessive swelling in your arms, legs, hands, or feet? - Select - Yes No

Do you have poor circulation in your legs? - Select - Yes No

Have you been, or are you currently inactive or replaced on bed rest? - Select - Yes No

Have you experienced any vaginal bleeding or abnormal discharge in the last 24 hours? - Select - Yes No

Do you have any serious disease(s) or contagious wounds? - Select - Yes No

Do you have any recently torn tendons, ligaments, or muscles? - Select - Yes No

Do you have any skin, bone or muscle diseases or infections? - Select - Yes No

During pregnancy, have you been consuming alcohol, abusing drugs, smoking, or ingesting any other teratogenic agents? - Select - Yes No

Are you experiencing or do you have any of the following? - Select - Yes No

• Placenta previa
• Cardiovascular disease
• Incompetent cervix
• Placenta abrupto
• Systemic lupus
• Uterine abnormality
• Diabetes
• Autoimmune factors
• Fractures or injected joints
• Fever

Please describe your current exercise habits: