Physical Activity Readiness Questionnaire (PARQ)
YOUR INSTRUCTOR WILL TREAT ALL INFORMATION CONFIDENTIALLY AND KEEP IT SECURE
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Email *
CLIENT INFORMATION
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Mobile Number *
Emergency Contact Name *
Emergency Telephone Number *
GP Practice Name & Address
Midwife Name
Midwife Telephone Number
Due Date
If this does not apply to you, please move on to the next question
MM
/
DD
/
YYYY
Number of Children *
Number of Weeks Pregnant
If this does not apply to you, please move on to the next question
MEDICAL HISTORY
Do you have, or have you ever experienced, any of the following health conditions? *
Yes
No
Shortness of breath
Miscarriage
Nerve damage during birth
Hypoglycaemia
Episiotomy / tears / perineum pain
Joint /muscle pain
Fainting or dizziness
Incontinence
Haemorrhoids / piles
Sciatica
Chest pain
Seizures / epilepsy
Heart disease
Pelvic/abdominal pain
Multiple births
Bleeding during or after exercise
Coccyx damage or pain
Prolapse
Varicose veins
Anaemia
High blood pressure
Symphysis Pubis Dysfunction (central pubic area pain)
Blood disorder
Arthritis
Diabetes / gestational diabetes
Carpel tunnel syndrome
Abdominal separation (diastasis recti)
Mastitis
C section wound discomfort / numbness
Postnatal depression / anxiety
If you answered 'YES' to anything within your medical history above, or you have / had suffered any other complications or health conditions, then please provide further details and whether you feel it could affect your ability to exercise *
IF YOU HAVE ANSWERED 'NO' TO ALL THE ABOVE MEDICAL CONDITIONS & HAVE NOT SUFFERED ANY OTHER COMPLICATION OR HEALTH CONDITIONS - SIMPLY ANSWER WITH "N/A"
Are you currently taking any medication?  If YES, please give details *
If NO, Please Answer with "N/A"
Please give details of your Pregnancy and / or Postnatal phase, including any complications, illnesses, reasons to visit your Doctor, or any other Health Practitioner including; Physiotherapy, Osteopathy, Massage, Pilates, Chiropractor etc. *
PHYSICAL ACTIVITY HABITS & INTENTIONS
Please give details of your previous and current exercise abilities / activities: *
Is there anything in your medical history that you feel could affect your ability to exercise? *
What are your goals for participating in our fitness classes and physical activity in general? *
Do you have any concerns about your pregnancy, birth or postnatal phase?  If so, please comment below.
POSTNATAL CLIENTS ONLY**
Date of delivery
MM
/
DD
/
YYYY
Type of delivery
6 week check-up outcome
Are you breastfeeding
Clear selection
Post-natal bleeding status
Did you have an episiotomy?
Clear selection
If you answered YES to one or more of the above Health Conditions
Talk to your GP by phone or in person before you start becoming more physically active.  Tell your GP about the questionnaire and which question(s) you answered yes to.  You may be able to do any activity you want – as long as you begin slowly and build up gradually, or you may need to restrict your activities to those which are safe for you.  Talk with your GP about the kind of activity you wish to participate in and follow his / her advice.
If you answered NO to the above Health Conditions
You can be reasonably sure that you are ready and able to start to become more physically active and take part in a suitable exercise programme.  Remember to start off exercising slowly and gradually build your physical activity levels.  
IMPORTANT
If your health changes at all and you develop any of the above health conditions or any other, then please inform your Fitness Instructor and Health Professional immediately.
DECLARATION *
I can confirm that I have read, understood and completed this questionnaire, consulted with my GP if necessary and that it is my responsibility to ensure the safety of myself and my baby when participating in any Mama & Me Fitness classes and that I can withdraw from the session at any time.
Required
I confirm that I have read and agreed to the Mama & Me Fitness terms & conditions, which can be found here: https://mamaandmefitness.co.uk/terms-conditions/ *
Required
Print Name (FULL CAPS) *
DATE OF DECLARATION *
MM
/
DD
/
YYYY
Would you like to join my mailing list and receive occasional newsletters, including advice, recipes, blog posts and offers? *
Where did you hear about Mama & Me Fitness? *
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