Pelvic Floor Reconnect

Pelvic Floor Reconnect

Client Health Pre-Screen Questionnaire
Your Questionnaire

Thank you for taking the time to fill out your client health questionnaire. We understand this is an extra thing to do but please take the time to answer all questions as honestly and fully as you can. Each question has been designed to carry out our duty of care. If you decide not to answer a question then that is fine but it may mean we cannot provide you with the best service and in some cases we may not be able to work with you until we have further information. Please note that we only use this information to ascertain whether we can help you, what we can help you with and to provide you with the best service possible. We will not share this information with anyone else.
Your Contact Details
Date

Month Day Year
Date
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City County

Postcode
Date of Birth

Month Day Year
Date
Email *
example@example.com
Phone Number

Area Code Phone Number

Your Medical Team

Use this section if you would like us to work alongside your medical professional or if we will need to consult with your medical team to make sure the exercises are right for your case. This is particularly relevant if you are recovering from prolapse surgery or similar.
Do you give permission for me to contact members of your medical team if it will help with our progress?

Yes No N/A
Please give details of the medical professional you would like us to contact. You may give more than one.
Please leave blank if not relevant.

Your Pregnancy History
Are you currently pregnant? *
How many times have you been pregnant?
We appreciate this can be a sensitive question so only answer if you wish.

Have you ever had multiple births? (Twins / Triplets)
How many children do you have?
Please give date(s) of delivery:
Please give details of any ailments you have experienced during your pregnancy and into the postnatal period including any reasons to visit the doctor, ask advice of your midwife or health visitor.
What type of delivery(s) did you have?
Please detail if you had vaginal birth, assisted (ventouse, forceps), c-section)
Have you had your 6 week postnatal check up (12 week for c-section)
The results of your postnatal check up?

Now create your own Jotform - It's free! Create your own Jotform

Your Questionnaire