PAR pregnancy Form | Donbavand Fitness

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.

Name

Date

Age

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when you perform physical activity?

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity?

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

Yes

No

Do you know of any other reason why you should not engage in physical activity?

Yes

No

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.

Occupation

Does your occupation require extended periods of sitting?

Yes

No

Does your occupation require repetitive movements?

Yes

No

If Yes

Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?

Yes

No

Does your occupation cause you mental stress?

Yes

No

Do you partake in any recreational physical activities (golf, skiing, etc.)?

Yes

No

If Yes

Do you have any additional hobbies (reading, video games, etc.)?

Yes

No

If Yes

Have you ever had any injuries or chronic pain?

Yes

No

If Yes

Have you ever had any surgeries?

Yes

No

If Yes

Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?

Yes

No

If Yes

Are you currently taking any medication?

Yes

No

If Yes

Additional Information

In the past, have you experienced:

Miscarriage in an earlier pregnancy?

Yes

No

Other Pregnancy Complicattions

Yes

No

I have completed this form in the last 30 days

Yes

No

If you have answered yes to any of the above 2 questions:

Number of previous pregnancies

Due Date:

During this pregnancy, have you experienced:

Marked fatigue?

Yes

No

Bleeding from the vagina ("spotting")?

Yes

No

Unexplained faintness or dizziness?

Yes

No

Unexplained abominal pain?

Yes

No

Sudden swelling of ankles, hands or face?

Yes

No

Pesistent headaches or problems with headaches?

Yes

No

Swelling, pain or redness in the calf of one leg?

Yes

No

Absense of fetal movement after 6th month?

Yes

No

Failure to gain weight after 5th month?

Yes

No

If you have answered yes to any of the above questions:

Disclaimer

I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.

I ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in the Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.

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