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Fill in PARm Form

Please note that we will generally only ask you to complete this assessment before the first time you participate in one of our Activities. However, if your physical condition changes in any way that could be relevant to our ability to act in the best interests of your health and safety, you must advise your teacher before participating in any Activities on any occasion.

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?

If you have answered YES to one or more of the above questions, consult your physician
before engaging in physical activity.
Tell you physician which questions you answered
YES to. After medical evaluation, seek advice from your physician on what type of
activity is suitable for your current condition.

Does your occupation require extended periods of sitting?
Does your occupation require repetitive movements?
Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?
Does your occupation cause you mental stress?
Do you partake in any recreational physical activities (golf, skiing, etc.)?
Do you have any additional hobbies (reading, video games, etc.)?
Have you ever had any injuries or chronic pain?
Have you ever had any surgeries?
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?
Are you currently taking any medication?

In the past, have you experienced:

Miscarriage in an earlier pregnancy?
Other Pregnancy Complicattions
I have completed this form in the last 30 days

During this pregnancy, have you experienced:

Marked fatigue?
Bleeding from the vagina ("spotting")?
Unexplained faintness or dizziness?
Unexplained abominal pain?
Sudden swelling of ankles, hands or face?
Pesistent headaches or problems with headaches?
Swelling, pain or redness in the calf of one leg?
Absense of fetal movement after 6th month?
Failure to gain weight after 5th month?

Activity habits during the past month:

Heavy Intensity
Medium Intensity
Light Intensity
Does your regular occupation (job/home) activity involve (Select all that apply):
Do you currently smoke tobacco?
Do you consume alcohol?

Physical Activity intentions

Is this a change from what you currently do?

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