Prenatal Physical Activity Readiness Questionnaire for Mpowered Fitness.

Prenatal Physical Activity Readiness Questionnaire for Mpowered Fitness.

For your own safely and wellbeing, and in order for us to tailor exercise to your needs, please provide the following information.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: 00000 000000.
DOB*

DayMonthYear
Date
What is your main reason for signing up to Mpowered Fitness?*
Emergency Contact's Name*

First NameLast Name
Emergency Contact's Number*
Please enter a valid phone number.Format: 00000 000000.
YesNo
If not, how many times have you given birth?
YesNoNot sure yet
YesNo
If yes, please give details:
Baby's estimated due date

DayMonthYear
Date
Pregnancy Health Conditions
Persistent 2nd/3rd trimester bleedingHemodynamically significant heart diseaseRestrictive lunge diseasePlacenta previa (after 6 weeks)Pregnancy-induced hypertensionIncompetent cervixRuptured membranesHyperemesis GravidarumGestational diabetesExtreme fatigueCarpal tunnel syndromeSymphysis pubic dysfunction/pelvic girdle pain (PGP)Sacrum/coccyx/sacroiliac painSciaticaPelvic floor dysfunction - pain, leakage (urine or faecal) or prolapsePiles or constipationCarpal tunnel syndromeAny joint aches and painsAny muscular aches and painsDiastasis recti (abdominal separation)Breathing problems
If yes to any of the above, please give details:
General Health Conditions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Please give an overview of any health/medical conditions & injuries*
Give a brief overview of your physical activity levels/regular exercise before pregnancy*
PhysiotherapistChiropractorAcupuncturistNone of the above
If yes to the above, please describe the reason for your visit(s)
Do you feel depressed or anxious / suffer with mood swings?*
Have you ever been diagnosed with postnatal depression or anxiety?*
Thank you so much for completing the postnatal PARQ questionnaire. If you have any concerns regarding the information you've provided, please contact marianna@mpowered.fitness. Please ensure that you feel well prior to each session and that you notify the trainer should you feel unwell at any time during the workout.
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Prenatal Physical Activity Readiness Questionnaire for Mpowered Fitness.

Pregnancy Health Conditions

General Health Conditions