Pregnancy PAR-Q – Bee MumFit

Name

First

Last

Date (DD/MM/YY)

Email

Number

DOB (DD/MM/YY)

Due Date (DD/MM/YY)

How many babies?

Single

Twins

More

Address

Midwife Details

Doctors Details

Emergency contact

Emergency Contact Number

Would like to be added to the What’s App Group?

Yes

No

I consent to photos being taken during class and used on social media?

Yes

No

General

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when performing physical activity?

Yes

No

Have you experienced chest pain when NOT performing physical activity in the last month?

Yes

No

Do you lose your balance because of dizziness or have you lost consciousness recently?

Yes

No

Do you have any bone or joint problems such as arthritis, which could be aggravated through physical activity?

Yes

No

Is your doctor currently prescribing you medications for high blood pressure or a heart condition?

Yes

No

Have you had an operation in the last 12 months?

Yes

No

Is there any reason why you should NOT participate in physical activity?

Yes

No

IF you answered YES to the final question or would like to add more details please state below:

Currently, or during any previous pregnancies have you ever suffered any of the following condition?

Symphysis pubis dysfunction (pain in the central public area)?

Yes

No

Sacrum or Sacroiliac Joint Pain (pain in the very low mid back – top of buttocks)?

Yes

No

Bleeding during or after exercise or any unexplained bleeding?

Yes

No

Carpal Tunnel Syndrome (Wrist/finger/hand forearm -pain/numbness or tingling)?

Yes

No

Knee Pain (Side, front or back)?

Yes

No

History Or Current Episodes of High/low blood pressure, episodes of faintness, dizziness or breathlessness, loss of consciousness?

Yes

No

Upper Back/Neck/Shoulder Pain?

Yes

No

Coccyx Damage or Pain?

Yes

No

Separation of your abdominal muscles?

Yes

No

Incontinence (Urinary or Faecal)?

Yes

No

Prolapse (Uterine, Bladder, Rectum, Vaginal)?

Yes

No

Breast Health/Breast Feeding Issues/Mastitis?

Yes

No

Piles/Haemorrhoids/Varicose Veins/Constipation?

Yes

No

Were you given an Epidural during a previous Birth?

Yes

No

Nerve Damage During a previous Birth (Pudendal)?

Yes

No

Gestational Diabetes?

Yes

No

C-Section wound discomfort or slow healing or ongoing numbness from previous birth?

Yes

No

Anaemia or taking Iron medication?

Yes

No

Joint Pain / Muscle Pain such as arthritis that could be aggravated by physical activity?

Yes

No

Buttock/Piriformis Pain/Sciatica?

Yes

No

Episiotomy Cut, Painful Perineum or Tears?

Yes

No

Any Severe and/or chronic itching?

Yes

No

Water retention / sudden swelling?

Yes

No

Rapid Weight gain?

Yes

No

Please detail any relevant/important information relating to previous Pregnancies and Post Birth periods, such as periods of illness or negative outcomes.

Are your midwife appointments and scans up-to-date? Are there any need to know details?

Please detail any home or work circumstances that might put constraints on your ability to commit fully in terms of time to your intended programme.

Are you able to count on your significant others for support in your journey?

Can you briefly detail your previous and current exercise abilities/activities?

Can you detail which fitness activities you like and dislike?

What is your sleep in general during pregnancy?

What are your current eating patterns?

What is your water intake each day?

How many times a day/night do you go to the toilet? Do you have any leaks? Any constipation?

If you answered no to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have low risk of having any medical

complications from exercise. It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a fitness instructor or personal trainer in order to determine where to begin.

PLEASE NOTE: If your health changes so that subsequently you answer YES to any of the above questions, inform your fitness or health professional immediately. Ask whether you should change your physical activity or exercise plan.

Declaration: I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Name

First

Last

Date (DD/MM/YY)

If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity. You should ask for a medical clearance along with information about specific exercise limitations you may have.

In most cases, you will still be able to do any type of activity you want as long as you adhere to some guidelines.

When to delay the start of an exercise program:

If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising. If you are or may be pregnant, talk with your doctor before you start becoming more active.

Declaration: Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise.

Name

First

Last

Date (DD/MM/YY)

PLEASE NOTE: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the 7 questions.

BY COMPLETING AND SUBMITTING THIS FORM YOU ARE CONFIRMING THAT YOU HAVE READ AND AGREE TO THE TERMS ABOVE.

Absolute Contradictions to Exercise During Pregnancy

2. Significant lung disease
3. Incompetent cervix
4. Multiple gestation at risk of premature labour
5. Persistent spotting/bleeding or Placenta Praevia
6. Premature labour
7. Ruptured membranes
8. Uncontrolled Type 1 Diabetes or Gestational Diabetes
9. Evidence of Intrauterine Growth Restriction
10. Pregnancy-induced Hypertension or Pre-Eclampsia
11. Uncontrolled epileptic fits / seizures
12. Any degree of Placenta Praevia

Please note number below and provide further information for any conditions