mumson the run

Physical Activity Readiness Questionnaire (PARQ)

for expectant and new mums

www.jogscotland.org.uk

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)

White: Scottish Other British Irish Other

Mixed: Any other background

Asian, Asian Scottish or Asian British: Indian Pakistani Bangladeshi Chinese Other

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 Sensory Learning

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 OrganiserPlease 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: Are you breastfeeding? Yes No

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: