Good For Mums: Post-Natal PAR-Q

Physical Activity Readiness Questionnaire (PAR-Q)

Personal Details

First Name *

Last Name *

Enter Email *

Date *

Address *

Phone Number *

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Doctors Surgery Name and Address

Pregnancy Details

Have you ever Birthed a Baby ?

Yes

How many times ?

Most Recent baby's Delivery Date

Have you had your 6-8 week check ?

Yes

N/A

Are you Pregnant

Yes

Are you under Midwife or Consultant led care?

N/A Midwife Consultant

If Consultant Led, Why ?

Types of Delivery - All That Apply

Vaginal

Vaginal Assisted Forceps

C Section (Planned)

Vaginal Assisted Suction Cap

C Section (Emergency)

Multiple birth (vaginal & section)

T Section

Where you given an Epidural or a Spinal Injection?

Yes No N/A

Are you still experiencing any bleeding ?

Yes No N/A

Did you experience a large amount of blood loss post birth? (excessive blood loss is anything over around 500ml)

Did you require any surgery post birth, if yes why?

Did you develop a post birth infection? If yes please explain the treatment provided.

Have you been diagnosed with Diastasis Recti (Abdominal muscle separation) ? *

Yes

Don't Know

N/A

Are you currently Breast Feeding? *

Yes

Have you recently had an IUD (coil) fitted? *

Yes

Did you tear or were you cut during birthing? Tick all that apply. (Tears of 3rd and 4th degree usually require you are rechecked by a doctor to check how the scars are healing and an internal examination) *

Episiotomy (surgical cut)

Superficial grazes (No stitches required)

1st Degree (tears to the labia, vaginal opening or anus which require few stitches and heal quickly)

2nd Degree (tears which are deeper into the muscle layers underneath and require 3-4 weeks to heal)

3rd Degree (tears which are deep into the muscle layers and extend to the anus)

4th Degree (tears which are deep, muscular and extend through the anal muscles)

Periuthreal Tear (tearing to the upper labia near the urethra, the tube from which you pass urine)

Are you currently taking part in any other forms of regular exercise? If yes, what? *

Do you experience any of these during or after exercise? *

Abdominal Cramps

Chest Pain

Dizziness

Feeling Feint

Shortness of Breath

Unexplained Vaginal Bleeding

If 'Yes' to any of the above, please give more details

Are you taking any regular medication, including supplements. *

Is there anything else about your pregnancy/birth/physical health that you would like to tell me? *

I can confirm that I have answered all the questions above honestly. I am aware that I must feel well prior to each class and will notify you (the trainer) should I feel unwell at any time during the class. I agree to inform my trainer if any of the previously disclosed information changes. I understand that i will be required to complete another health screening form in the event of surgery, long periods of absence, annually. I am aware that my trainer will check my abdomen for a condition called Diastasis Recti and this involves her touching my stomach. I understand that i may be required to obtain consent from a Doctor before commencing exercise. I am aware the trainer may take photos/videos during the classes and i agree to them being used on social media unless i ask the trainer not to include me in any images. Images of children are sometimes captured during classes, these will not be shared on social media without the permission of the parent. Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for women, I understand that my participation and the safety of both my child/children and myself are my responsibility. I understand that Good for Mums is registered with the Information Commissioners Office (ICO) and complies with GDPR. I understand that by completing this PAR-Q my email address is added to the Good for Mums mailing list. However, the email address is only used to contact you regarding relevant information and is not used for marketing or shared with any third parties. I am aware i can unsubscribe from this mailing list at any time by clicking the unsubscribe link on the emails or by asking Good for Mums. Your personal data within this health screening form is secured safely and only information which is relevant is collected. In line with HMRC, The ICO and The Federation of Holistic Therapists (FHT) guidelines, I am obliged to securely retain this data for a period of 10 years from the date of this form.

I have read and understood this declaration * *