Strength In Mumbers PAR-Q

1
Name* This field is required.
First Name
Last Name
2
Your Date of Birth* This field is required.
Date
Day
Month
Year
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email Address* This field is required.
example@example.com
5
Your Phone Number* This field is required.
6
Name and phone number of your emergency contact* This field is required.
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Small
Ok
Ok
7
Are you pregnant?* This field is required.
YESNO
8
Have you had a baby/stopped breastfeeding in the last 6 months?* This field is required.
YESNO
9
Are you currently breastfeeding or have breastfed within the last 6 months?* This field is required.This is to find out whether your body is still producing the hormone 'relaxin'.
YESNO
10
When did you last give birth?* This field is required.
11
Please detail any complications you had in your pregnancy or labour.* This field is required.Please think very carefully and detail everything. Even if you may think it is minor.
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Ok
12
What type of birth did you have?* This field is required.
Vaginal
Planned c-section
Emergency c-section
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Did you have an episiotomy?* This field is required.
YESNO
14
Were any tools used to assist your birth? * This field is required.Forceps, ventouse etc.
15
Are you experiencing any form of incontinence?* This field is required.
YESNO
16
Have you been checked for diastasis recti? (Separation of the abdominals)* This field is required.
YESNO
17
If yes, what was the outcome?
18
Name and date of birth of your child/children* This field is required.Please only detail those who will be attending classes
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Small
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Ok
19
Please give details of any physical activity you have taken part in, in the past 12 months.* This field is required.
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Large
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Ok
20
Please give any details regarding your/your child's health that you think we may need to be aware of.* This field is required.
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Ok
21
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?* This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this current time and in your current state of health.
YESNO
22
Do you feel pain in your chest whilst doing physical activity?* This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this time and in your current state of health.
YESNO
23
In the past month, have you experienced chest pain whilst NOT doing physical activity?* This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this current time and in your current state of health.
YESNO
24
Do you lose balance because of dizziness or lose consciousness? * This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this current time and in your current state of health.
YESNO
25
Do you have a bone or joint problem that could be made worse by change in your physical activity?* This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this current time and in your current state of health.
YESNO
26
Is your doctor currently prescribing medication for your blood pressure or heart condition?* This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this current time and in your current state of health.
YESNO
27
Do you know of any other reason why you should not take part in physical activity?* This field is required.If your answer is yes, you should consult with your doctor to clarify whether it is safe for you to become physically active at this current time and in your current state of health.
YESNO
28
If you answered yes to the above question, please give details.
29
I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities that may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves some risk of injury. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.* This field is required.
I agree
I do not agree
30
I confirm that I am at least 6 weeks postnatal (10 weeks for C-section) and that my child is my own responsibility (whilst attending in-person classes). It has been explained to me that all of the exercises demonstrated in the class are suitable for postnatal women. It is my own responsibility to choose a level that I am comfortable working at. * This field is required.
I agree
I do not agree
31
I will notify my instructor if any of the above details change in the future. * This field is required.
I agree
I do not agree
32
How did you hear about our classes?* This field is required.
33
Signature
34
Date
Date
Day
Month
Year
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