POST NATAL PAR-Q

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Do you current or have you ever suffered any of the following conditions? (Tick all relevant))

Symphysis Pubis Dysfunction (pain in the central pubic area)

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

Upper Back/Neck/Shoulder Pain

Lack of total Bladder/Bowel Control (Urinary or Feacal Incontinence)

Piles/Haemorrhoids/Varicose Veins/ Constipation

After Effects of Gestational Diabetes

Joint Pain

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

Knee Pain (Side/front)

Coccyx Damage or Pain

Prolapse (Uterine, Bladder, Rectum, Vaginal)

Were you given an Epidural during birthing?

C-Section wound discomfort or slow healing or ongoing numbness

Buttock/Piriformis Pain/Sciatica

Bleeding during or after exercise or any unexplained bleeding

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

Diastasis (Separation of your abdominal muscles)

Breast Health/Breast Feeding Issues

Nerve Damage During Birthing (Especially Pudendal)

Anaemia or taking Iron medication

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

None of the above

I confirm that I take sole responsibility for my child when they are present during any gym classes or personal training sessions with SC-Fitness and will not hold SC-Fitness responsible for the safety or care of my child. *

I confirm that I am happy for SC-Fitness Personal Training to store my personal information and data as long as it is necessary to the service I will receive in line with the GDPR act 2018.