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PARQ for Mum & Baby Pilates

THIS FORM IS REALLY IMPORTANT!

This is a PARQ (pre Activity Readiness Questionnaire) This tells us all about you, any ailments or injuries that you may have. 

Please complete it in depth, allow me to help you, all forms are treated with the strictest of confidence.

Thank you

Vicky x

Grab a cuppa and click the button below to start. Please be aware that by clicking back you may lose all your data. If you have a long paragraph to write it may be worth copy and pasting from another document/notes just in case! 

Start

Question 1 of 17

What is your name & DOB?

Question 2 of 17

What is the name and age of your child(ren) that you will be bring to class with you?

Question 3 of 17

If applicable do you have any on going complications, ailments or health issues from your pregnancy?

For example; SPD, blood pressure, hernias

Question 4 of 17

If applicable, please tell me about your last delivery. When did you give birth, did you have a c-sec or vaginal delivery, are you still breast feeding & do you have any on going recovery complications? Or anything you think I should know.

Question 5 of 17

Please indicate if you have ever experienced any blood pressure, cardiac or respiratory issues or been diagnosed with a condition related to the above?

If yes, please give details.

Question 6 of 17

Has your Doctor ever said that you have a heart condition, and that this would impact upon physical activity?

If yes, please give details.

Question 7 of 17

Have you ever had chest pains whilst doing physical activity?

If yes, please give details below.

Question 8 of 17

Do you have a bone or joint problem likely to be exacerbated by exercise?

If yes, please give details.

Question 9 of 17

Is your doctor currently prescribing you heart or blood pressure medication?

If yes, please give details:

Question 10 of 17

Do you know of any other reason that you should not partake in physical activity?

If yes, please give details.

Question 11 of 17

Please indicate if you are taking and medication, prescribed or other

Question 12 of 17

Do you smoke?

Question 13 of 17

Have you undergone any surgery in the last 12 months?

If yes, please give details.

Question 14 of 17

Is there anything that you feel I need to know about yourself and your health and physical wellbeing the may be effected or taken into consideration with exercise?

Question 15 of 17

Please give details of both your doctors surgery (including phone number) and your next of kin.

Please note that in a case of emergency I may contact both.

Question 16 of 17

What physical problems of concerns do you have that you are hoping to tackle and conquer through this core course. 

For example; weak back, diastasis recti, weak hips. 

Question 17 of 17

Have you participated in, or have experience attending a Pilates class before?

If so how long ago & how regular did you go to class?

Confirm and Submit