Physical Activity Readiness Questionnaire (PAR-Q) Ante & Post Natal

Physical Activity Readiness Questionnaire (PAR-Q) Ante & Post Natal - Peri/Post Menopause + COVID-19
This Par-Q form is designed to identify adults for whom physical activity maybe inappropriate or for those who should have medical advise concerning the type of exercise most suitable for them. For most people Physical activity should not post any problem or hazard.

All information provided is confidential and will be kept in a secure place.

No information is shared with a third party, unless written consent is given by you, the client, first. For instance a GP or Womens Health Physical Therapist I may feel necessary to contact on your behalf, but this would only take place with your permission.
COVID-19

https://www.nhs.uk/conditions/coronavirus-covid-19/
Name

First NameLast Name
Date today
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postal Code
Mobile

Area CodePhone Number
Home Phone
Date of Birth

MonthDayYear
Date
Age
Occupation
Emergency contact Name /Relationship & Phone number/s
GP
Midwife
Have you recently been experiencing any symptoms of Covid-19 ? If yes please give details
Have you ever experienced symptoms of Covid-19? If yes please give details
Have you ever tested positive for Covid-19? If yes please give details
Have you been abroad in the last two weeks ? If yes please give details
If you are unsure about symptoms or anything to do with Covid-19 there is a link to the NHS website above. Alternatively contact your GP/Midwife for advise. If you are currently experiencing symptoms or have in the last 2 weeks please end the questionnaire here and submit. I will be in touch shortly after receiving the questionnaire
Health Questionnaire
Date of Delivery
Type of Delivery (Vaginal/C-Section) Including any intervention such as Forceps/Epidural
Do you suffer from any C-Section wound discomfort/slow healing or ongoing numbness? If YES, explain
Did you Tear or receive an Episiotomy (Degree if known)
Do you suffer with a painful perineum ? (The area between your vagina and anus)
Have you had your 6-8 week Post Natal check up & what was the outcome?
Breastfeeding status
Breast Health / Feeding issues?
Post Natal Bleeding Status
Any Ante Natal Bleeding?
How many children do you have and what are their age ?
Have you or do you still have Gestational diabetes ?
Blood Pressure (if known, or even just high, low)
Are you currently pregnant ? How many weeks ?
If currently pregnant, has your midwife/GP given you the all clear to begin or continue exercise?
If pregnant, please give me details on how your pregnancy is progressing and any issues you maybe experiencing no matter how small.
Do you currently or have you ever suffered with any of the following conditions? If you answer YES please give details.
Piles/Haemorrhoids/Varicose Veins
Symphysis Pubis Dysfunction(SPD -Pain in the central pubic area)
Carpel Tunnel Syndrome (Wrist/finger/hand or forearm pain or numbness/tingling)
Sacrum or Sacroiliac Joint Pain (Pain in the very low mid back - top of buttocks)
Upper Back/ Neck /Shoulder Pain
Knee Pain (side/Front)
Coccyx Damage or Pain
Joint Pain
Do you suffer from Buttocks/Piriformis Pain/Sciatica?
High/Low Blood Pressure, episodes of faintness, dizziness or breathlessness, history of thrombosis or blood clots?
Do you feel pain in your chest when doing physical activity ?
Has your doctor ever given you a reason not to partake in any form of physical activity?
Can you think of any reason why you should not take part in any physical activity?
Have you ever experienced any unexplained bleeding during or after exercise?
Are you on any medication? Please include supplements
I have read and understand the questions in this Par-Q form and I have answered to the best of my knowledge and with honesty. Any questions I had were answered to my full satifaction.

Please sign below and continue scrolling down to the deeper pre screening PFD questionaire.
Signature

PELVIC FLOOR QUESTIONAIRE
Pelvic Floor Dysfunction (PFD) may present in a wide variety of symptoms and in order for me to understand and to help you understand why your pelvic floor isnt working optimally or like it used to do, you'll need to fill out the following questions as honestly and fully as possile please. If you answer yes to any of them, please provide details.

The answers to the following questions will give me a clearer idea on how move forward and get you back to great pelvic health and core harmony.
1) Have you ever had a Rec check/ abdominal check for split abdominal muscles (Diastasis Recti)? If yes who was it performed by and what were the results please ?
2) Are you experiencing any difficulty with your bowel, wind or urinary urges? i.e sudden urge to go from nowhere? If YES Please add details
3) Do you lose urinary continence / wind continence or faecal continence when laughing/sneezing/running/ jumping or moving to quickly? Leaking? IF YEs please give details
4) Are you incontinent at night during sleep? If YES please give details
5) Do you currently or or have you ever had to were incontinence pads? If yes, how many in a day would you normally wear?
6) Do you suffer from constipation or regularly have to strain when on the toilet. Do you have to assist your own voiding ? If YES please give details
7) Are your bowel movements or urination painful ?
8) Do you experience a sense of PRESSURE in your vagina or rectum or have you noticed any protrusions from your orifices (vagina & anus). This may only be when you are on your period. If YES please give details
9) Have you ever been diagnosed as having a prolapse? If yes what type & grade ?
10) Do you experience pain with intercourse or sexual stimulation?
11) Do you have any numbness in the saddle area ( The part of your body that would touch a saddle when riding)? Can you feel yourself when you wipe?
12) Do you experience any pain in your genitals ?
13) Do you experience pain inside or at the joints of your pelvis?
14) Are you or have you ever been a competitive athlete? I.e Runner, Gymnast, trampolining or any contact sports?
15) Do you frequently lift heavy weights ? (Gym, work, children, caring for elderly/disabled)
16) Have you ever sustained an injury to the pelvic region or injury to your Coccyx (fracture, radiotherapy) If YES please give details
17) Have you ever undergone any gynaecological surgery (e.g. Hysterectomy, fibroids removal, prolapse repair). If YES please give details
18) Do you or have you ever had a chronic cough/sneezing/ or a condition that affected your breathing (smoking, asthma, hay fever). If YES please give details
19) Are you or have you been overweight ?
20) Are you going through or have you been through the menopause?
21) On a scale of 1-10, how much are you troubled/affected but your Pelvic Floor/Incontinence Issues? 1 = A little, 10 = Very concerned
22) What is the problem - in your own words?
23) How long have you been aware of or concerned by a change in your continence and/or pelvic floor function? Please give ANY DETAILS of previous attempts at improving your pelvic floor function, or write no attempt to sort out.
24) What liquids do you drink throughout the day and how much of each type?
25) How is your health in general? Do you need to tell me about any other health issues you have ?
Please use this space to tell me anything you think I should know about. Any referrals you have had and the reason/outcome.
I have read and understand the questions in this PFD questionaire, I have answered to the best of my knowledge and with honesty.

Any questions I had were answered to my full satifaction.

Please sign below
Signature
Should be Empty:

Physical Activity Readiness Questionnaire (PAR-Q) Ante & Post Natal - Peri/Post Menopause + COVID-19

COVID-19

Health Questionnaire

PELVIC FLOOR QUESTIONAIRE