R.A.B.B PAR-Q FORM

Name: *

First

Last

Date of birth:

Address:

Class or event attending:

Rock-A-Bye Babies

How did you find out about us?

Phone number:

Email address: *

ABOUT YOU: 1. Have you been diagnosed with a heart condition and advised not to take part in physical activity?

Yes
No

2. Do you have chest pain brought on by physical activity?

Yes
No

3. In the past month, have you developed chest pain when not doing physical activity?

Yes
No

4. Do you lose your balance as a result of dizziness or lose consciousness?

Yes
No

5. Do you have a bone/joint problem that could worsen by a change in physical activity?

Yes
No

6. Has a doctor ever recommended medication for your blood pressure or a heart condition?

Yes
No

7. Are you aware through your own experience or from doctor’s advice or any other reason why you should not do physical activity?

Yes
No

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 *

First

Last

Emergency contact phone number:

ABOUT YOUR BIRTH: 1. Is this your first pregnancy?

Yes
No

2. Have you experienced any complications during pregnancy, birth or post-partum?

Yes
No

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.

Premature birth
Large baby (8lbs+)
Multiple birth

5. Did you tear or require an episiotomy?

Yes
No

6. Have you been given the postnatal 6 week check by your midwife or doctor?

Yes
No

7. Have you been given permission to exercise by your midwife or doctor following your postnatal check?

Yes
No

8. Are you continuing to see your midwife?

Yes
No

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:

Yes
No

If Yes, please circle how we can communicate with you:

Email
Text message
Phone call

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)

Yes
No

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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