Prenatal PAR-Q If you are planning to join the training of FitnessByMaria, start by answering the questions below. Please read the questions carefully and answer each one honestly: Circle YES or NO. You will need to provide a doctors approval before starting your first workout while being pregnant. Full name Date of birth (dd-mm-yyyy) Pre-Natal Health Checklist Setting Boundaries Throughout our coaching partnership, there may be things that come up that you are or are not comfortable talking about. Topics such as your menstrual cycle, pelvic floor health, nutrition, sleep, and stress may all have an impact on your training and your results to varying degrees. Please indicate which topics you are comfortable talking about with me as your coach by checking the box (or check the first box if you are comfort- able talking about all of them). If you are not comfortable talking about these issues with me, leave the box blank. (Please note you may change your decision at any time). As you go through the rest of this form, feel free to leave the questions that you do not feel comfortable answering blank. I am comfortable talking about any of the topics below: Pelvic floor health YesNo Incontinence YesNo Menopause YesNo General health status In the past, have you experienced: Miscarriage in an earlier pregnancy? YesNo Other pregnancy complications? YesNo If you answered YES to question 1 or 2, please explain: Number of previous pregnancies? Status of current pregancy Due Date (dd-mm-yyyy): During this pregnancy, have you experienced: Marked fatigue? YesNo Bleeding from the vagina (“spotting”)? YesNo Unexplained faintness or dizziness? YesNo Sudden swelling of ankles, hands or face? YesNo Persistent headaches or problems with headaches? YesNo Swelling, pain or redness in the calf of one leg? YesNo Absence of fetal movement after 6th month? YesNo Failure to gain weight after 5th month? YesNo If you answered Yes to any of the above questions, please explain: Activity habits during the past month List only regular fitness/recreational activities Does your regular occupation (job/home) activity involve: Heavy Lifting? YesNo Frequent walking/stair climbing? YesNo Occasional walking (>once/hr)? YesNo Prolonged standing? YesNo Mainly sitting? YesNo Normal daily activity? YesNo General health checklist Do you currently smoke tobacco? YesNo Do you consume alcohol? YesNo Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YesNo Do you feel pain in your chest when you do a physical activity? YesNo In the past month, have you had chest pain when you were not doing physical activity? YesNo Do you lose balance because of dizziness or do you ever lose consciousness? YesNo Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity? YesNo Is your doctor currently prescribing any medication for your blood pressure or heart condition? YesNo Do you know of any other reason why you should not do physical activity? YesNo