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hello@poweredfromwithin.com +447813030408

17A Hurn Way, Christchurch, BH23 2NT

Home
Sports Massage
Personal Training
Classes
Get in touch

Pre Exercise & Lifestyle Questionnaire (PAR-Q)

Please complete the form with as much detail as possible. If you have any questions, please contact me on 07813 030408

Contact Us

Please give as much detail on any ticked issues at the end of the par-q

Personal Details

First name:

Surname:

Email:

Phone:

Mobile:

Address (continuous line please)

Date of birth:

No. of Weeks Pregnant / Post Natal (if applicable)

Free Text

Next of Kin Details

Name:

Phone No.:

Alternative number:

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Healthcare details

GP Name:

GP Practice:

GP Phone No.:

Attending hospital

Midwife (if applicable)

Field label

EXERCISE HISTORY

Previous exercise history

Exercise goals

Any medical history that could affect exercise

Free Text

MEDICAL HISTORY

How 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

incompetent cervix

Multiple gestation at risk of premature labour

Persistent spotting/bleeding or Placenta Praevia

Non-persistent spotting/bleeding

Spotting/bleeding during/after exercise

Premature labour

Miscarriage

Ruptured membranes

Uncontrolled type 1 diabetes

Gestational diabetes

Evidence of intrauterine growth restriction

Pregnancy-induced hypertention or pre-eclampsia

Uncontrolled epileptic fits/seizures

Dyspnoea (dificult 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 noticable appearance of puffiness

Itchiness

Noticable increase in thrist

Symphsis pubis dysfunction

Sacrum or sacrroiliac joint pain

Knee pain

Lower back pain

Upper back/neck pain

Coccyx damage or pain

Separation or abdominal muscles (diastsis)

Urinary/fecal incontinence

Prolapse

Piles

Varicose veins

Carpal Tunnel Syndrome/Wrist pain

PLEASE PROVIDE ANY FURTHER DETAILS FOR TICKED CONDITIONS ABOVE:

Are you taking any medication?

Free Text

POSTNATAL CLIENTS ONLY

Date of delivery

Type of delivery (vaginal, assisted, c-section)

6-8 week check-up date and outcome

Postnatal bleeding status?

Are you breastfeeding?

Recently fitted IUD?

Have you suffered/needed any of the following?

Epidural during birthing

C-section wound discomfort or slow healing/numbness

Buttock/piriforms 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 INFORMATION YOU CAN ON YOUR PREVIOUS PREGNANCY AND POSTNATAL HISTORY, POSSIBLE COMPLICATIONS FROM YOUR MEDICAL BACKGROUND OR OTHER HEALTH PRACTITIONERS VISITED:

PRINT NAME:

DATE:

How did you hear about us:

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Get in touch

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17A Hurn Way
Christchurch
BH23 2NT

07813 030408
hello@poweredfromwithin.com

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