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
membership@jogscotland.org.uk, 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:
.