PAR-Q First NameLast NameAddressAddress Line 1Address Line 2CityCountyPost CodeMobile numberEmailOccupationDate of Birth – dd/mm/yyyyNumber of Weeks Pregnant/PostnatalHow did you hear about us?Next of KinNext of Kin details: NameContact NumberAlternative Contact DetailsHealthcare DetailsHealthcare DetailsGP NameGP PractiseGP Phone NumberAttending HospitalMidwife (If Applicable)HistoryYour Medical HistoryHow Many Births Have you Had? Previous Birth Experience/Problems (Vaginal/Assisted/C-Section)Have You Experienced Any of The Following Either Past or Present? Significant Heart Disease Significant Lung Disease Uncontrolled Type 1 Diabetes Incompetent Cervix Multiple Gestation at Risk of Premature Labour Persistent Spotting/Bleeding or Placenta Previa Non Persistent Spotting/Bleeding Premature Labour Miscarriage Ruptured Membranes Uncontrolled Type 1 Diabetes Gestational Diabetes Evidence of Intrauterine Growth Restriction Pregnancy-Induced Hypertension or Pre-Eclampsia Uncontrolled Epileptic Fits/Seizures Dyspnoea (Difficult Breathing) Before Exertion Dizziness Headache Chest Pain Calf Pain or Swelling Previous Decreased Foetal Movement Suspected Amniotic Fluid Leakage Dramatic Recent Weight Gain Swelling or General Noticeable Appearance or Puffiness Itchiness Noticeable Increase in Thirst Symphysis Pubis Dysfunction Sacrum or Sacroiliac Joint Pain Carpal Tunnel Syndrome/Wrist Pain Knee Pain Lower Back Pain Upper Back/Neck Pain Coccyx Damage or Pain Separation or Abdominal Muscles (Diastasis) Urinary/Faecal Incontinence Prolapse Piles Varicose VeinsAny Other Injuries Past or Present to be Aware of?Previous Exercise History & Regular Fitness or Recreational ActivitiesAny Medical History That You Feel Could Affect Your Ability to Exercise?Are You Taking Any Medications?Other Medical History Background and Other Health Practitioners Visited What Are Your Goals for Participating in Exercise?PostnatalFor Postnatal Client onlyPlease Provide Any Further Information You Can on Your Previous Pregnancy and Postnatal History, Possible Complications from Your Medical Background or Other Health Practitioners VisitedDate of Delivery – dd/mm/yyyyType of Delivery – (Vaginal, assisted, C-section)6-8 Week Check-up Date dd/mm/yyyy6-8 Week Check-up OutcomePostnatal Bleeding statusAre You Breastfeeding? Yes No OtherOther- Please explainRecently Fitted IUD?Have You Suffered/Needed Any of the Following Epidural During Birthing C-Section Wound Discomfort or Slow Healing/Numbness Buttock/Piriformis Pain/Sciatica Breast Health/Breast Feeding Issues Nerve Damage During Birthing (Especially Pudendal) Anaemia or Taking Iron Medication Episiotomy Cut, Painful PErineum or Tears (Degree if Known)Please Provide any Further Details for Ticked Conditions AbovePlease Provide Any Further Information You Can on Your Previous Pregnancy and Postnatal History, Possible Complications From Your Medical Background or Other Health Practitioners VisitedThank you Thank you for taking time to complete the PAR-Q carefully. This form has been emailed to Ginette@poweredfromwithinpt.com . Feel Free to get in touch if you have any questions or problems in completing this form. Send Details
