The Motherhood Project: PRENATAL Intake
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Your first name *
Your last name *
City you live in *
Your due date *
Your cell # *
Emergency contact name and # *
How did you hear about The Motherhood Project: Pre and Postnatal Wellness?
PAR-Q: Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. (Check YES or NO)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
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Do you feel pain in your chest when you do physical activity? *
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In the past month, have you had chest pain when you were not doing physical activity? *
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Do you lose your balance because of dizziness or do you ever lose consciousness? *
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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? *
Required
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Required
Do you know of any other reason why you should not do physical activity? *
Required
If you answered "YES" to one or more of these questions:
• Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
• You may be able to do any activity you want, as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
• Find out which community programs are safe and helpful for you.
If you answered "NO" to all of these questions:
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
• start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
• take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your blood pressure is higher than 144/94, talk with your doctor before you start becoming much more physically active.

You should DELAY becoming much more active if:
• if you are not feeling well because of a temporary illness such as a cold or a fever, wait until you feel better.
• if you are or may be pregnant, talk to your doctor before you start becoming more active.

PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
PRENATAL FOLLOW UP
A little about your experience and history please
Were you physically active prior to pregnancy? *
Is this your first pregnancy? *
If you answered "no" above, did you experience any notable complications in a previous pregnancy, labour or deliver?
Clear selection
If you answered YES above, please explain *
Are you experiencing any physical discomfort at this time (for example: fatigue, hip, back, pelvic or other)? *
If you answered YES above, please explain
Are you experiencing any emotional discomfort at this time (for example: anxiety, depression etc)? *
If you answered YES/MAYBE above, please explain
Have you seen a pelvic floor physiotherapist during this pregnancy? *
Do you have a history of infertility or pregnancy loss? *
If you answered YES above, please explain
Is there anything else you would like us to know about your pregnancy/prenatal experience?
The Motherhood Project: Pre + Postnatal Wellness and Thrive Movement Studio Waiver
WARNING: THIS DOCUMENT WILL AFFECT YOUR LEGAL RIGHTS, READ IT CAREFULLY!
Every participant must read and understand this Waiver and Release of Liability prior to participation. I, the applicant, on behalf of myself, members of my family, my heirs, executors, administrators and assigns, hereby release, discharge and hold harmless The Motherhood Project: Pre + Postnatal Wellness and any subsequent host facility including Thrive Movement Studio Inc., Tong Louie YMCA, City of Surrey, City of Delta, and their representatives and agents for all known and unknown personal injuries to me or to my unborn child, loss or damage to my person or property howsoever caused, arising out of or in connection to my taking part in group fitness training activities and not withstanding that the same may have been contributed to or occasioned by negligence of the group fitness instructor, personal trainer or their representatives or agents. By signing this document, I acknowledge and agree with the following: I have consulted with my physician or midwife with respect to my participation in physical activity, and s/he has informed me of the risks (if any) inherent in my participation, and I have obtained his/her permission to participate. I agree to limit my participation to only the level of activity which is comfortable to me in my physical condition at that time. I acknowledge that I am solely responsible for any loss of or damage to any personal property that I bring with me to class. I hereby certify that I am at least 18 years of age, and that I have read this document carefully, understand each term and provision in its entirety, have agreed to the terms freely and voluntarily. Having read the above, I knowingly agree to accept full responsibility for my own exposure to any risks that may arise during my participation in prenatal fitness and/or prenatal yoga with The Motherhood Project: Pre + Postnatal Wellness at any host facility including, but not limited to Thrive Movement Studio Inc., Tong Louie YMCA, City of Surrey, City of Delta. *
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First and Last name *
YES! I would like to receive important information and updates from The Motherhood Project. I understand I can opt out of the newsletter at any time. *
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Thank you for taking the time to complete our intake! We welcome you to our community and look forward to working with you!
-The Motherhood Project: Pre + Postnatal Wellness and Thrive Movement Studio
hello@themotherhoodproject.ca
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