Postnatal Exercises

Name*

Email*

DOB

ADDRESS

Date of Delivery

CONSULTANT/DOCTOR

HOSPITAL

Phone

NAME OF CONTACT:

RELATIONSHIP

TEL NO

ALTERNATIVE TEL NO

A- General Health

Has your doctor ever said that you have a heart condition? If YES, please give details.

Yes
No

Do you feel pa n in your chest when you do physical activity?

Yes
No

In the past month, have you had chest pain when you were not doing physical activity?

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes
No

Do you have back/pelvic or other joint problem that could be made worse by a change in your physical activity?

Yes
No

Do you suffer from raised blood pressure? If YES, is this pregnancy related and how is it being treated?

Yes
No

Do you suffer from diabetes? If YES, is this pregnancy related and how is it being treated?

Yes
No

Do you suffer from asthma? If YES, how is this controlled?

Yes
No

Do you know of any other reason that could affect your participation in exercise?

Yes
No

Regular physical activity is fun and healthy, especially during pregnancy. However, we would recommend that you complete and check this questionnaire with your doctor before embarking on any new activity programme.

When answering the following questions, common sense is your best guide. Please read the questions carefully and answer each one honestly. (All responses will be treated with the strictest of confidence).

D - Postnatal Health

Has your doctor ever said that you have a heart condition? If YES, please give details.

Yes
No

What type of delivery did you have?*

Normal vaginal delivery
Forceps delivery
ventose/kiwi/suction delivery
caesarean section

Are you breastfeeding?

Yes
No

Have you had your postnatal check-up?

Yes
No

Was everything satisfactory at your postnatal check-up? If NO, please give details

Yes
No

Are you/were you a regular exerciser before pregnancy? If YES, please give details

Yes
No

Did you participate in physical activity during pregnancy? If YES, please give details

Yes
No

Do you do/intend to do any other exercise in addition to this programme?

Yes
No

Please add any additional comments or concerns:

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Phone

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Screening Questionnaire for Postnatal Exercise (PARQ)

Postnatal PARQ

A- General Health

D - Postnatal Health