Enhanced PARQ for expectant and new mums
Transcription
Enhanced PARQ for expectant and new mums
Physical Activity Readiness Questionnaire (PARQ) for expectant and new mums www.jogscotland.org.uk s m u m un on the r Section 1 (Please complete all sections) Membership No. (if a current Member) Title: Forename: Surname: Address: Postcode: Date of Birth:Email: Home Telephone:Work Telephone: Mobile: Membership Category: If you are interested in full membership tick here: Group Name: N.B Local session charges may apply. Ethnic Origin (optional) Scottish Other British White: Mixed: Any other background Asian, Asian Scottish or Asian British: Indian Other Irish Other Pakistani Bangladeshi Chinese Other Ethnic Background: Any other ethnic background Disability (optional): Please indicate whether you regard yourself as having a disability: Yes No If yes, please indicate which category your disability fall into: Physical Learning Sensory And please state what the disability is: Research : If you consent to participate in jogscotland member activity and health research please tick this box. jogscotland will use your membership details to send you information and materials relating to your membership. Occasionally we may wish to send you information from other organisations including jogscotland sponsors. If you do not want to receive this information please tick this box On each email we send you will be given the option to opt out of receiving future emails. This will not affect your membership renewal reminder. Information is collected and processed in accordance with the Data Protection Act 1998 and the Privacy & Electronic Communications (EC Directive) Regulations 2003. Jog Leader/ Local Organiser Please keep the completed section 2 PARQ for your own records and send the details from Section 1 to [email protected], preferably using the jogscotland membership template spreadsheet. Section 2 Physical Activity Readiness Questionnaire (PARQ) Your Jog Leader needs to be aware of your health history and how active you have been recently so that you can be led through a safe and effective exercise programme. The only people that will have access to your details are your Jog Leader(s) and jogscotland staff. Person to contact in case of emergency Name:Relationship: Home Telephone:Work Telephone: Mobile: Midwife:Contact Number: What are your goals for participating in exercise? What other activities do you regularly? Section A – For Women Who are Currently Pregnant Is this your first pregnancy? Yes No What is your due date? How many other children to you have? Have you experienced any of the following past or present? (please tick)* Relative Contraindications to Aerobic Exercise During Pregnancy* Guidance from the Royal College of Obstetricians and Gynaecologists Absolute Contraindications to Aerobic Exercise During Pregnancy* www.rcog.org.uk Severe anaemia Hemodynamically significant heart disease Unevaluated maternal cardiac arrhythmia Restrictive lung disease Chronic bronchitis Incompetent cervix / cerclage Poorly controlled type 1 diabetes Multiple gestation at risk of premature labour Extreme underweight (BMI <12) Persistent second or third trimester bleeding Extreme morbid obesity Placenta previa after 26 weeks of gestation History of extremely sedentary lifestyle Premature labour during the current pregnancy Intrauterine growth restriction in current pregnancy Ruptured membranes Poorly controlled hypertension Preeclampsia / pregnancy induced hypertension Orthopaedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker *IMPORTANT – If Yes to any of the above please discuss with your GP/ Health Professional before exercise Section B – For Post Natal Women Only Has your doctor/ health professional completed your 6-8 week postnatal check? Yes No Baby’s Date of Birth:Delivery Type: No Are you breastfeeding? Yes Section C – To Be Completed by All Women Have you experienced any of the following past or present? (please tick)* Sudden swelling of ankles, hands of face High/Low blood pressure Headaches, dizziness or faintness Chest pains Abdominal pain or cramping Heart attack Back, pelvis or pubic pain Unusual changes to baby’s movements during pregnancy Vaginal bleeding, fluid loss or spotting Joint problems Shortness of breath Diabetes Fatigue Miscarriage *IMPORTANT – If Yes to any of the above please discuss with your GP/ Health Professional before exercise Please provide any other health or medical information you feel your instructor should be made aware of. Are you participating in this activity AGAINST your doctor’s advice? Yes No Formal Declaration I can confirm that I have had the all clear by my GP to commence exercise. I am aware that I must feel well prior to each class and will notify you (The Leader) should I feel unwell at any time during the class. Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for me to participate, I understand that my participation and the safety of both my child/children and myself is my responsibility. I take part entirely at my own risk and waive any legal recourse for damages to myself and/or my child(ren) or property arising from my participation. Signed: Date: .