In order to assess what programme is right for you, I’d like you to assist me by answering the following questions as fully as possible. The answers you provide will help me to help you. This ensures that I can thoroughly assess your suitability and if further help is required outside the scope of exercise I can also assist you in finding this help. Thank you.The information that you provide will remain COMPLETELY CONFIDENTIAL. Please rest assured that the information you provide on this form WILL NEVER BE SHARED. Your privacy is extremely important to us.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number (no dashes)
-
Area Code
Phone Number
WhatsApp Number (no dashes)
-
Area Code
Phone Number
Postnatal History
Have you ever given birth?
Yes
No
Please answer yes or no to the following questions. Answer YES even if you only partially agree with the statement. Then use the space below to give further details.
*
Yes
No
N/A
If you are early Postnatal, are you still breastfeeding?
If you are early Postnatal, have you had your 6-8 week check? *
Do you have separation of your abdominal muscles at the midline (Diastasis)?
Did you develop excessive stretch marks in pregnancy?
Please give full details of how you gave birth (Vaginal, c-section, episiotomy etc)
*
History
Please answer yes or no to the following questions. Answer YES even if you only partially agree with the statement. Then use the space below to give further details.
*
Yes
No
N/A
Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly? Or leak without warning?
Do you experience any urinary hesitancy, starting/stopping of your urine stream or incomplete emptying?
Do you currently or have you ever needed to wear incontinence pads?
Do you often think you need to go to the toilet to urinate - 'just in case'?
Do you lack the ability to hang on if you have to urinate or have a bowel movement?
Are you incontinent overnight or wake in the night often to urinate?
Are your bowel movements or urination painful?
Are you experiencing difficulty with your bowel, wind or urinary urges?
Is there any blood present in either your stools or urine?
Have you ever suffered with any bowel conditions such as IBS, Colitis or are you a Coeliac?
Do you have a DAILY bowel movement?
Do you suffer from constipation or regularly strain on the toilet? Do you need to assist your own voiding?
Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Has anyone ever said you may have a prolapse?
Do you have any problems wearing or inserting tampons?
Do you experience pain in your genitals and/or pelvis with or without sexual intercourse?
Do you currently or have you ever suffered with cystitis?
Do you experience pain inside or at the joints of your pelvis?
Are you currently pregnant?
Are you going through or have you been through the menopause?
Have you had or do you still have varicose veins?
Have you ever undergone any gynaecological surgery (eg. hysterectomy, fibroid removal etc)?
Have you had any major surgery or trauma to your body?
Are you or have you ever been an advanced recreational or professional athlete? Runner, gymnast, trampolining or any sport that involved regular contact or blows to your abdomen?
Do you have a history of low back pain or any other type of back pain?
Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx)?
Does your work / daily activity involve lots of sitting, walking or lifting?
Are you hypermobile?
Do you frequently lift heavy weights (gym, work, carer, children)?
Are you or have you ever been overweight?
Do you suffer any other medical conditions?
Are you on any medication?
Do you have either Type 1 or Type 2 Diabetes?
Do you take any hormone correction medication?
Have you ever been diagnosed with a Thyroid issue or taken any Thyroid medication?
Are you currently or previously taking any Anti-anxiety or Anti-depressant medication?
Do you add sugar to your food or drink?
Are you on a special diet ie., vegetarian/vegan?
Do you have any intolerances/allergies?
Are you taking any supplements currently?
If you answered YES to ANY of the above questions, please give further information in the space below
*
Please rate the following on a scale of 1 - 10. (Use the horizontal scroll bar to see other values)
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1
2
3
4
5
6
7
8
9
10
On a scale of 1-10, how much are you troubled by your Core/Pelvic Floor issues? 1 = "a little" 10 = "very concerned
On a scale of 1-10, how would you rate your day-to-day life stress levels? 1 = "not stressed" 10 = "very stressed
In your own words - what is/are the problems? What are your reasons for seeking help via this program? Please detail any previous attempts to improve your situation.
*
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