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Date of Birth
Health Care Practitioner and Address
Pregnancy Due Date
Number of weeks pregnant
What are your reasons for wanting to start this Programme?
Do you attend any other classes?
What is your current exercise level?
I do not exercise at all
I exercise once a week
I exercise regularly 2-3 times a week
I exercise more that 3 times a week
Is this your first pregnancy?
Is this a multiple pregnancy?
If yes, please add more information
Have you ever experienced any of the following conditions in this pregnancy or any other pregnancies?
Calf pain/ swelling
Previous preterm labour
Decreased Foetal movement
Suspected amniotic fluid leakage
Dramatic weight loss or weight gain
Swelling and puffiness
If you have answered yes to any questions above this is a contraindication to exercise in pregnancy, please provide more details below and visit your health practitioner for approval before commencing the programme.
Currently or in any previous pregnancies have you suffered from any of the following conditions?
Low back pain
Upper back pain
Carpal tunnel syndrome
Separation of tummy muscles
Symphysis pubis dysfunction (SPD)
Sacrum or SIJ pain
Cocyxx damage or pain
If you have answered yes to any questions above please provide more details
I will advise my instructor before commencing any session if, for any reason, your health or ability to exercise changes. I will check with my doctor/midwife at regular intervals (at antenatal check ups) if it is still ok for you to exercise. I will tell the teacher if I feel any discomfort, dizziness, nausea or pain during the session. I will inform my instructor if I feel discomfort or pain after a previous session.
If it is advised by my medical practitioner to stop exercising or experience any of the following symptoms while exercising (vaginal bleeding, pain, heaviness in the vagina, contractions or feeling of faintness/dizziness) I will stop the programme immediately.
I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the exercise professional administering the exercise program provided to me. All medical questions and concerns about should be directed to my own Doctor and/or Midwife and I agree to do so. I can confirm that I have read and understood the PARQ.