PARQ & Class Payment Form Mummy & Me Fitness

Pre and postnatal physical activity readiness questionnaire
Name *

First Name Last Name
Email *
example@example.com
DOB *

Month Day Year
Date
Contact Number *
Address:
Areas of interest

Nutrtion Breastfeeding Weight gain How pregnancy changes your body Exercise The pelvic floor Diastasis Recti (ab seperation) Other
Are you pre or postnatal? *

Prenatal Postnatal
How many weeks/month postnatal are you? *
How many months/weeks pregnant are you? *
Current and/or previous exercise plan:
Have you ever experienced any of the following, past or present? Please tick. *

Shortness of breath Chest pains Misscarriage Eating disorders Vaginal disorders or Pelvic floor issues Blood disorders Heart disease Arthritis Incompetent cervix Multiple gestation Diabetes Multiple births High blood pressure Hypoglycaemia Any joint problems or mobility issues Premature labour risks Placenta previd Preeclampsia Persistent uncontrolled bleeding Uncontrolled hypertension Other
Is there anything in your medical history that you feel could affect your ability to exercise?

Yes No
If yes, please provide more information:
Are you taking any medication? *

Yes No
If yes, please specify:
Is there anything about your pregnancy or birth you may feel is relevant to your participation in an exercise programme? This includes any diagnostics in pregnancy and/or issues you've had since having baby that could be worsened by exercise.
What concerns you most about pregnancy, birth or the postnatal period?
What are your goals for participating in physical activity with in the next 6 weeks?
What are your medium term goals (3 months)?
What are your long term goals (6 months plus up to 1 year)?
In your opinion, do you eat a healthy well balanced diet?
Would you say you would like to (tick as many as you like)

Lose weight safely Maintain weight at the moment Work on my post pregnancy body with care Correct/repair any birth injuries Slowly get my self back into a fitness routine Nurture my body and prepare it for birth as I grow my beautiful baby Maintain current pregnancy fitness levels
Prenatal use from here
Date baby was born: *

Month Day Year
Type of delivery:
Did you tear?

Yes No
Did you have an assisted delivery? Episiotomy, Forceps or Ventouse etc.
Postnatal, do you know if you have diastasis recti (ab separation)? If yes, please specify how many cm. If you are not sure, we will do the assessment together.
Are you breastfeeding?
Are you napping during the day? Does your baby sleep on a night? (Don't worry if not, I feel ya!)
Anything else. Any other medical conditions or birth injuries I need to know about? Or are there any concerns you may have in participating in exercise?
Todays Date:

Month Day Year
Postnatal clients must of had the all clear at the 6-8 week checkup from GP & midwife.

Prenatal clients but seek advice from their GP and/or midwife before starting any exercise programme.

For Trainer use only:

After review and interpretation of the information gathered, I can confirm that there are no contraindications present.
Signature:

Clear

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Prenatal use from here