CIMSPA Certified Personal Trainer, Pre/Post Natal and Nutritional coach

Motivasi Post Natal ParQ

Post Natal Physical Activity Readiness Questionnaire
(To be completed after booking a package option)

Purpose: A PAR-Q is designed to show the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. If you have any issues completing this form, please use the contact detail below.

E-mail: info@motivasi.co.uk

Full Name *

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Date of Birth*

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E-mail*

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The e-mail address is invalid

What Previous exercise did you do before pregnancy?*

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Are you doing any other exercise now?*

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What are your goals or reasons for participating in exercise?*

This field is mandatory

Type of delivery?*

This field is mandatory

Are you breastfeeding?*

This field is mandatory

Are you getting up at night?*

This field is mandatory

How much sleep are you getting?*

This field is mandatory

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

This field is mandatory

Are you taking any medication? (Please give details)*

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Do you current or have you ever suffered any of the following conditions? If YES please select boxes below or write inside the box.*

This field is mandatory

Symphysis Pubis Dysfunction (pain in the central pubic area)

Sacrum or Sacroiliac Joint Pain (pain in the exceptionally low mid back – top of buttocks)

Bleeding during or after exercise or any unexplained bleeding

Carpal Tunnel Syndrome (Wrist/finger/hand forearm -pain/numbness or tingling)

High/low blood pressure, episodes of faintness, dizziness or breathlessness, history of Thrombosis or blood clots

Knee Pain (Side/front)

Upper Back/Neck/Shoulder Pain

Coccyx Damage or Pain

Prolapse (Uterine, Bladder, Rectum, Vaginal)

Breast Health/Breast Feeding Issues

Piles/Haemorrhoids/Varicose Veins/ Constipation

C-Section wound discomfort or slow healing or ongoing numbness

Anaemia or taking Iron medication

Episiotomy Cut, Painful Perineum or Tears (Degree if known)

After Effects of Gestational Diabetes

I hereby agree that this data will be stored and processed for the purpose of establishing contact and creating a personalised fitness program. I am aware that I can revoke my consent at any time.*

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* Indicates required fields

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