PPNPARQ

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Postnatal physical activity readiness questionnaire

Thank you for signing up for my course. In order to provide you with a safe and appropriate exercise please fill out the questionnaire below.

First name

Last name

Email

Age

Address

Mobile nr

Date baby was born * required

Type of delivery

Did you have an episiotomy?

Have you ever experienced any of the following, past or present? * Required

Shortness of breath

Chest pains

Eating disorder

Seizures

Vaginal disorder

Heart disease

Hypoglycaemia

Vaginal bleeding

Arthritis

Diabetes

High blood pressure

Knee problems or pain

Back problems or pain

Neck problems or pain

Leaking urine when sneezing, laughing

SPD

None of the above

If yes to any, please specify.

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

If yes, please specify.

Are you taking any medication?

If yes, please list medications here.

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

If yes, please specify.

What concerns you most about your postnatal period?

What are your goals for participating in physical activity?

Are you breastfeeding?

How many times are you getting up at night?

Are you napping during the day?

Your Signature

Date * required

It is advisable to speak with your doctor or midwife before commencing an exercise programme.

I want to subscribe to the newsletter.

I agree to the terms & conditions.

Photograph preference. Please select one or more of the following options regarding the use of photographs. * Required

I allow photoes of both myself and my baby to be taken and used on social media.

I allow photoes of myself, but not my baby to be taken and used on social media.

Don't use photoes where my baby's face is visible.

Don't use photoes where my face is visible.

I don't allow any photoes to be used about me and my baby.

I allow the same photoes to be used on the website's gallery and in Newsletters.

Form submitted successfully.

Thank you for completing your registration.

See you soon!

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