Par-Q Questionnaire for Pregnancy Name(required) Address(required) Phone number(required) Email(required) Date of birth (DD/MM/YY) Proposed class start date (YYYY-MM-DD)(required) Number of weeks pregnant(required) Health Care Provider (HCP) – GP & Midwife details(required) Emergency contact name(required) Emergency contact number(required) General Par-Q 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Yes No 2. Do you feel pain in your chest when you do physical activity? Yes No 3. In the past month, have you had chest pain when you were not doing physical activity? Yes No 4. Do you lose balance because of dizziness or do you ever lose consciousness? Yes No 5. Do you have a bone or joint problem (for example back, knee, hip) that could be made worse by a change in your physical activity? Yes No 6. Is your doctor currently prescribing medication for your blood pressure or heart condition? Yes No 7. Do you know of any other reason why you should not do physical activity? Yes No If you answered yes to above question, please provide more information below Pregnancy Specific Screening Currently, or during previous pregnancies, have you suffered any of the following conditions? Please tick any that apply to you. Symphysis Pubis Dysfunction (SPD Carpal Tunnel Syndrome Upper Back Pain Separation of your ab muscles Sacrum or SIJ Pain Knee Pain Neck Pain Varicose Veins Bleeding during pregnancy Lower Back Pain Coccyx Damage or pain Gestational Diabetes On the following questions, please provide as much detail as possible. Reason for joining KelFit?(required) Last visit to Primary Health Provider and outcome? Scan results?(required) History of miscarriages?(required) How many times a day do you go to the toilet (including through the night)? Any leaks?(required) How has your sleep been throughout your pregnancy?(required) Briefly describe your current eating habits(required) What number pregnancy is this for you?(required) First Second Third Fourth Fifth If you have older child(ren), how old are they, and what kind of birth(s) did you have? Please respond yes or no to the following: Any excessive or sudden swelling and water retention? (required) Yes No Any skin rashes, open or unhealed cuts or bruises?(required) Yes No Any history or blood clots or Thrombosis?(required) Yes No Any extreme calf pain, swelling or redness?(required) Yes No Any severe and chronic itching?(required) Yes No Extreme high blood pressure – current and previous history? (required) Yes No Any excessive thirst and urination? (required) Yes No Any rapid or large weight gain while pregnant? (required) Yes No Any varicose veins or haemorrhoids? (required) Yes No Current multiple pregnancy (twins/triplets etc.)?(required) Yes No Any constipation?(required) Yes No Disclaimer: “I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and have sought the necessary clearance from my HCP”. Signature(required) Today's date (YYYY-MM-DD)(required) For KelFit use only: Antenatal notes seen? HCP clearance received, where applicable? Telephone consultation completed? NOTE: Contraindications to Exercise Listed below are the current guidelines on ABSOLUTE CONTRAINDICATIONS to exercise. Please inform me immediately if you have experienced any of the following conditions (in this pregnancy) or have been told by your HCP that you have them. Please select any condition you are experiencing/have experienced: Significant heart disease Significant lung disease Incompetent cervix Multiple gestation at risk of premature labour Persistent spotting/bleeding or Placenta Praevia Premature labour Ruptured membranes Uncontrolled Type 1 Diabetes or Gestational Diabetes Evidence of Intrauterine Growth Restriction Pregnancy-induced Hypertension or Pre-Eclampsia Uncontrolled epileptic fits/seizures Please provide further information if you have ticked any of the above options Submit Δ Share this:TwitterFacebookLike this:Like Loading...