The Mummy MOT Pre-Screening Questionnaire
Any problems or queries, please contact the physiotherapist who directed you here.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Who asked you to complete this form?
How many weeks post natal are you?
What was your pre-pregnancy weight?
What is your weight now?
What concerns are you experiencing since delivering?
Please answer the following questions. If you answer YES to any question, please provide further information in the box below.*
Type a question
Rows
Yes
No
N/A
Have you had your 6 week check with your GP?
Do you have any medical problems?
Are you on any medication?
Did you have any problems/conditions before pregnancy?
Did you have any complications during pregnancy?
Have you undergone any gynaecolgical surgery?
Have you ever suffered any bowel condition such as IBS, colitis etc?
Are you breastfeeding?
Have you ever been diagnosed with SPD, SI joint or PGP?
Are you hyper mobile? (BHMS or EDS)
Have you developed excessive stretch marks in pregnancy?
Do you have separation of your abdominal muscles at the midline? (DIASTASIS)
Are you finding it hard to activate your pelvic floor muscles?
Do you have incontinence when you cough, laugh, sneeze, exercise or lift?
Do you have urinary frequency? (going often)
Do you have urinary urgency? (rushing to go)
Do you need to wear incontinence pads?
Do you have bowel incontinence?
Do you have bowel urgency?
Do you have pain when emptying your bowel?
Do you feel that you empty your bowel completely?
Do you ever assist emptying?
Have you ever been diagnosed with organ prolapse (POP)?
Do you experience a sensation of pressure or pain in the vaginal or rectal area?
Do you have any discomfort when inserting or wearing tampons?
Do you have any hormonal imbalance problems?
Do you have a thyroid disease? (under or over)
Do you have a history of recurrent UTIs?
Do you suffer with chronic Candida?
Have you been on a course of antibiotics?
Do you have a history of endometriosis?
Do you have pain during intercourse?
Do you have Coccyx pain ?
Do you have a good urinary flow when you empty your bladder?
Do you have a history of lower back pain?
Have you had a c section?
Has it healed well?
Do you have pain at the scar?
Is the scar adherent?
Have you had perineal stitches?
Do you have any pain sitting?
Do you have any pelvic floor dysfunction? (hypertonic, hypotonic, pudendal nerve)
Did you exercise during pregnancy?
Are you currently exercising?
Do you have any other conditions you feel are relevant?
If you answered YES to any of the above questions please give further details below:*
Submit
Should be Empty: