Post Natal Physical Activity Readiness Questionnaire (PARQ)

Name*

First Last

Date of Birth:*

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email*

Phone number:*

Emergency name and contact:*

Doctor:

Surgery Number

Date of Delivery:

Baby's Name:

Number of children:

please enter a number, do not write the number eg. 1, 2, 3 etc. not one two three

Type of Delivery, including position if vaginal (Assisted, Vaginal, C-Section, episiotomy, tear):

6-8 Week Check-Up Date & Outcome:

Breastfeeding Status:

Post Natal Bleeding Status:

Recently Fitted IUD?

Are you still getting up in the night? Napping during day?

Do you currently or have you ever suffered from low moods?

Please give details of your Pregnancy & Post Natal, include any complications, illnesses, reasons to visit your Doctor or any other Health Practitioner including Massage, Acupuncture, Pilates, Physiotherapy, Osteopathy, Chiropractor etc.

Do you currently or have you ever suffered any of the following conditions? Please tick YES or NO

1. Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise, or might be made worse by exercise?*

Yes
No

Do you have high blood pressure?*

Yes
No

Do you have low blood pressure?*

Yes
No

Do you have Diabetes Mellitus or any other metabolic disease?*

Yes
No

Has your doctor ever said that you have raised cholesterol (serum level above 6.2mmol/L)?*

Yes
No

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

Have you ever felt pain in your chest when you do physical exercise?*

Yes
No

Is your doctor currently prescribing you drugs or medication?*

Yes
No

Have you ever suffered from unusual shortness of breath or chest pain at rest or with mild exertion?*

Yes
No

Is there a history of Coronary Heart Disease in your family?*

Yes
No

Do you often feel faint, have spells of severe dizziness or have lost consciousness?*

Yes
No

Do you suffer from seizures?*

Yes
No

Do you currently exercise on a regular basis (at least 3 times a week) and/or work in a job that is physically demanding?*

Yes
No

Are you, or is there any possibility that you might be, pregnant?*

Yes
No

Do you know of any other reason why you should not participate in a program of physical activity?*

Yes
No

Do you currently or have you ever suffered any of the following conditions?

Symphysis Pubis Dysfunction (pain in the central pubic area)
Carpal Tunnel Syndrome (Wrist/finger/hand forearm pain/numbness or tingling)
Upper Back/Neck/Shoulder Pain
Lack of total Bladder/Bowel Control (Urinary or Feacal Incontinence)
Piles/Haemorrhoids/Varicose Veins/ Constipation
After Effects of Gestational Diabetes
Joint Pain
Vaginal Disorder
Vaginal Bleeding

Sacrum or Sacroiliac Joint Pain (pain in the very low mid back – top of buttocks)
Knee Pain (Side/front)
Coccyx Damage or Pain
Prolapse (Uterine, Bladder, Rectum, Vaginal)
Were you given an Epidural during birthing?
C-Section wound discomfort or slow healing or ongoing numbness
Buttock/Piriformis Pain/Sciatica
Incomplete cervix
Acid Reflux or Digestion Issues

Bleeding during or after exercise or any unexplained bleeding
Bleeding during or after exercise or any unexplained bleeding
Diastasis (Separation of your abdominal muscles)
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)
Pelvic/ abdominal cramps
Thrush (recently)

Please give more details where necessary on any of the above points:

Previous exercise:*

Is there anything in your medical history that you feel could affect your ability to exercise?

What concerns you most about pregnancy, birth, or the postnatal period?

If you have a c-section scar (or any other scar you feel is relevent) I will offer to include some ScarWork Therapy in our session. If you have a scar and would like ScarWork treatment, please give more details here. Do you have numbness or sensitivity? Are you aware of any pulling or restriction to movement? Are you aware of any mesh?

Is there anything about your pregnancy or birth you feel is relevant to your participation in an exercise programme?

Do you have any specific dietary requirements?

Client's Name:*

First Last

Assumption of risk*

Assumption of Risk and Informed Consent

Exercise programmes are designed to improve muscle tone, strength, endurance and flexibility and may include physical activities such as stretching, using weights and equipment/machines.

When participating in activity/exercise you are likely to experience different levels of intensity over varying lengths of time. As a result you may experience quicker breathing patterns and become hot, as well as feelings of awkwardness depending on your experience or level of fitness.

Each part of the activity/exercise/massage you participate in will be fully explained, you are strongly advised to ask questions if you are not clear about anything.

I confirm that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities which may include aerobic exercise, resistance exercise, stretching, and release or massage work using a foam roller, instrument assisted massage, ScarWork massage or massage therapy. I realise that my participation in these activities involves the risk of injury and even the possibility of death. I understand that I am fully responsible for the welfare of my baby at all times and will not participate in any activity that I feel is not safe with my baby. If at any time I feel any pain or discomfort, I will stop performing the activity and notify the instructor. Likewise, if I feel that I should not do a particular exercise for any reason I understand that I must inform the instructor.

I agree to seek medical advice and treatment for any conditions indicated on this form (any question I have answered Yes to), such as pelvic organ prolapse, incontinence, pelvis and back pain, as Vanessa Barker cannot treat these. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, and my instructor will need to be informed of any changes in my condition. It is further expressly agreed that all strength training, cardiovascular exercise, or any other exercise shall be undertaken by me at my sole risk and that Vanessa Barker shall not be liable to me for claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located.

Any information provided by Vanessa Barker is not intended to be a substitute for professional medical advice from a doctor, nutritionist or dietician. You must not rely on this information as an alternative to medical advice, and Vanessa Barker expressly disclaims all responsibility and liability for any damages, loss or injury suffered by you or any third party as a result of this information.

Training includes general nutrition advice, and as with all dietary programmes, you must get your physician’s approval prior to making any changes to your diet, for diagnosis and treatment of illnesses, and for advice regarding medications. Nothing provided is intended as medical advice and is not intended to replace the advice or attention of health‐care professionals. Always consult your physician before beginning or making any changes in your diet and/or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications. This is not a medical treatment and I am not receiving the treatment from Vanessa Barker in any medical capacity. No diagnosis has been given.

I have read and understood the above assumtion of risk statment and agree to everything contained within.

I confirm that I have acted or will act on any issues arising from the questions on this form and have obtained the medical advice where required (as indicated on the form).

I understand that I am free to withdraw my consent and to withdraw from the activities at any time, without negative consequences.

I consent to the use of visual images (photos, videos etc.) involving my participation in the activities. This will be for use in my marketing, but I will check with you before taking and sharing any photos. You do not have to tick this box if you do not consent to this.

Use of Data Collected and Privacy Policy.*

Once you submit this data it is kept on a secure website until I download it, at which point I delete the online copy.

I will keep a password encrypted PDF copy on my laptop (password protected and protected by McAfee LiveSafe) and on a password encrypted KnowHow Cloud Storage as back up.

This information is for me to ascertain whether training/massage is suitable, if so what adaptations I may need to take into account, and whether I need to refer you to a Health Care Provider such as your GP or a Physio. The only circumstances under which I will share any information is if you do indeed see another professional, and give me permission to send them details about why I have referred you, including what training I hope to do with you, so as to get their advice on how to proceed.

I will have a hard copy of some information to bring to our sessions. Session notes have your name, DOB, address and phone number at top. These are kept in a locked filing cabinet.

I will keep this information, as well as records of any sessions we have, until 7 years after you cease training with me,as this is the length of time my insurance requires I retain them, in keeping with The Statute of Limitation in the UK. At the end of this period, or if you have completed this questionnaire but do not subsequently train with me I will delete all data, and use McAfee to shred deleted files. I will shred the hard copies of session notes.

If you would like a copy of the PDF I have please let me know and I will send you all the information I have.

With regards to communication, I am not currently using an email encryption programme. Any emails we send to each other may be vulnerable to viruses or human error. If you send me an email, this can be seen on my personal phone which is password protected. Most emails and text messages will be deleted once they have been read/actioned. However it may be necessary for me to keep some messages if they are relevant to our training.

I understand that the information obtained in this personal fitness training programme will be treated as confidential and will consequently not be released or revealed to any person without my express written consent.

I understand I have the right to have personal data rectified if it is inaccurate or out of date, and will inform Vanessa Barker of necessary changes.

I understand I may request in writing a copy of any of my personal data Vanessa Barker has stored.

Date*

Client’s signature:

Date

Pelvic Floor Dysfunction Questionnaire

This may seem personal, and even irrelevant to you: if so, that’s great. However over 50% of women suffer continence issues after having children, and in fact, many who haven’t had children do too. This is a sign of a weakness in the pelvic and core area, and if not addressed it can cause worse problems in the future, such as prolapse. And again, 50% of women suffer some form of prolapse after having children, so it is important you’re honest so we can discuss and address any problem. Pelvic Floor Dysfunction (PFD) may present via a wide variety of symptoms and in order to help us to help you understand why your Pelvic Floor isn’t working as well as it used to, you’ll need to answer the following questions as fully as possible. The answers to the following questions will give us both a clearer idea of how to move forward and get you back to great core and Pelvic Health.

Are you experiencing difficulty with your bowel, wind or urinary urges?

Yes
No

If yes, please state which.

Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly?

Yes
No

Do you struggle to 'let go' and begin a stream of urine or bowel movement?

Yes
No

Are your bowel movements or urination painful?

Yes
No