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R.A.B.B PAR-Q FORM
R.A.B.B PAR-Q FORM
Date of birth:
Class or event attending:
How did you find out about us?
Social media- Facebook, instagram or twitter
Online search engine
ABOUT YOU: 1. Have you been diagnosed with a heart condition and advised not to take part in physical activity?
2. Do you have chest pain brought on by physical activity?
3. In the past month, have you developed chest pain when not doing physical activity?
4. Do you lose your balance as a result of dizziness or lose consciousness?
5. Do you have a bone/joint problem that could worsen by a change in physical activity?
6. Has a doctor ever recommended medication for your blood pressure or a heart condition?
7. Are you aware through your own experience or from doctor’s advice or any other reason why you should not do physical activity?
Please outline any other relevant information that may affect your ability to exercise: known allergies, pre-existing medical conditions, current medication etc.
If you select ‘YES’ in response to any of the questions above, you may need your GP’s consent before participating in a Rock-A-Bye Babies class.
Emergency contact name
Emergency contact phone number:
ABOUT YOUR BIRTH: 1. Is this your first pregnancy?
2. Have you experienced any complications during pregnancy, birth or post-partum?
If yes, please give more detail:
3. What type of delivery did you have?
Other (please specify)
4. Have you had any of the following? Please tick those that apply.
Large baby (8lbs+)
5. Did you tear or require an episiotomy?
6. Have you been given the postnatal 6 week check by your midwife or doctor?
7. Have you been given permission to exercise by your midwife or doctor following your postnatal check?
8. Are you continuing to see your midwife?
Please tick to acknowledge:
I have read, understood and completed this questionnaire. I understand that it is my responsibility to read and follow the manufacturer’s guidelines for my sling/carrier and that I need to ensure it is safe for use for my child.
I understand that it is my responsibility to monitor mine and my baby’s physical condition at all times. I agree to take part in this class at my own risk and Expressions Academy CIC will not be responsible for any injury or loss or harm of any kind that may result directly or indirectly from taking part in Rock-A-Bye Babies, other than that which is caused by negligence.
CONTACT WITH EXPRESSIONS: Do you consent to your data being added to our database for communication purposes, eg information about future events and newsletters:
If Yes, please circle how we can communicate with you:
Do you consent to your data being added to our database so we can use your details at future events (and prevents the need for additional forms to be completed)
Do you give permission for Expressions Academy to record and use video footage or photographic images of yourself for website, social media and future advertising.
I do give permission
I do NOT give permission
Date of form completed and submitted:
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March 3, 2024