Pregnancy Form

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Patient Referral Form

Pregnancy Form

Aspire Fit Pregnancy & Women's Health

PARmed-X for PREGNANCY

Physical Activity Readiness Medical Examination

First Name*

Last Name*

Cell Phone*

Birthday*

Absolute Contraindications (Check if YES, leave blank if NO.)

Ruptured Membranes, premature labor? Persistent second or third trimester bleeding/placenta previa? Pregnancy-induced hypertension or pre-eclampsia? Incompetent cervix? Evidence of intrauterine growth restriction? High-order pregnancy (e.g., triplets)? Hypertension or thyroid disease Cardiovascular, respiratory or systemic disorders

Relative Contraindications (Check if YES, leave blank if NO.)

History of spontaneous abortion or premature labor in previous pregnancies? Mid/moderate cardiovascular or respiratory disease? Anemia or iron deficiency (HB<100g/L)? Malnutrition or eating disorder (anorexia, bulimia)? Twin pregnancy after 28th week?

Physical Activity Recommendation:

Recommended/Approved Contraindicated

(701) 225-3536

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