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17A Hurn Way, Christchurch, BH23 2NT

Home
Sports Massage
Personal Training
Classes
Get in touch

Pre Exercise & Lifestyle Questionnaire

Pregnancy & PostNatal

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:

How did you hear about us:

Email:

Phone:

Mobile:

Occupation:

Date of birth:

No. of Weeks Pregnant / Post Natal

Address (continuous line please)

Free Text

Next of Kin Details

Name:

Phone No.:

Alternative number:

Free Text

Healthcare details

GP Name:

GP Practice:

GP Phone No.:

Attending hospital

Midwife (if applicable)

Free Text

HISTORY

How many births have you had?

Previous birth experience/problems (vaginal/assisted/C-section)

Previous exercise history & regular fitness or recreational activities

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

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

Any medical history that you feel could affect your ability to exercise?

Any general concerns about pregnancy, birth or the postnatal period

what are your goals for participating in exercise?

are you taking any medications?

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 know)

PLEASE PROVIDE ANY FURTHER DETAILS FOR TICKED CONDITIONS ABOVE:

PLEASE PROVIDE ANY FURTHER INFORMATION YOU CAN ON YOUR PREVIOUSPREGNANCY AND POSTNATAL HISTORY, POSSIBLE COMPLICATIONS FROM YOUR MEDICAL BACKGROUND OR OTHER HEALTH PRACTITIONERS VISITED:

PRINT NAME:

SIGNATURE:

DATE:

Field label

THANKYOU FOR TAKING THE TIME TO COMPLETE THE PAR-Q CAREFULLY.

PLEASE SAVE THE COMPLETED FORM TO YOUR HARD DRIVE AND THEN EMAIL IT TO GINETTE@LUCINAFITNESS.COM

FEEL FREE TO GET IN TOUCH IF YOU HAVE ANY QUESTIONS OR PROBLEMS IN COMPLETING THE FORM.

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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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