PARQ | Powered From Within

PAR-Q

First Name

Last Name

Address

Address Line 1

Address Line 2

City

County

Post Code

Mobile number

Occupation

Date of Birth – dd/mm/yyyy

Number of Weeks Pregnant/Postnatal

How did you hear about us?

Next of Kin

Next of Kin details:

Name

Contact Number

Alternative Contact Details

Healthcare Details

GP Name

GP Practise

GP Phone Number

Attending Hospital

Midwife (If Applicable)

History

Your Medical History

How Many Births Have you Had?

Previous Birth Experience/Problems (Vaginal/Assisted/C-Section)

Any Other Injuries Past or Present to be Aware of?

Previous Exercise History & Regular Fitness or Recreational Activities

Any Medical History That You Feel Could Affect Your Ability to Exercise?

Are You Taking Any Medications?

Other Medical History Background and Other Health Practitioners Visited

What Are Your Goals for Participating in Exercise?

Postnatal

For Postnatal Client only

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

Date of Delivery – dd/mm/yyyy

Type of Delivery – (Vaginal, assisted, C-section)

6-8 Week Check-up Date dd/mm/yyyy

6-8 Week Check-up Outcome

Postnatal Bleeding status

Are You Breastfeeding?

Yes

Other

Other- Please explain

Recently Fitted IUD?

Have You Suffered/Needed Any of the Following

Epidural During Birthing

C-Section Wound Discomfort or Slow Healing/Numbness

Buttock/Piriformis 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 Details for Ticked Conditions Above

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

Thank you

Thank you for taking time to complete the PAR-Q carefully. This form has been emailed to Ginette@poweredfromwithinpt.com . Feel Free to get in touch if you have any questions or problems in completing this form.