Intake Form

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Nicol * * Email * Area Code * Phone Number *
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Setting Boundaries.Throughout our coaching partnership, there may be things that come up that you are or are not comfortable talking about. Topics such as your menstrual cycle (or lack thereof), pelvic floor health, nutrition, sleep, and stress may all have an impact on your training and your results to varying degrees. Please indicate which topics you are comfortable talking about with me as your coach by checking the box (or check the first box if you are comfort- able talking about all of them). If you are not comfortable talking about these issues with me, leave the box blank. (Please note you may change your decision at any time). As you go through the rest of this form, feel free to leave the questions that you do not feel comfortable answering blank.
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Type a question
Please Select
Please Select
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I am comfortable talking about any of the topics below:* This field is required.
Birth experience
Menstrual cycle
Pelvic floor health
Diastasis recti
Incontine Pelvic organ prolapsence
Menopause
Breastfeeding
C-section recovery
Emotional issues (e.g.,depression, anxiety)
Body image
Nutrition
Weight
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Other (please list)
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Are you ?
Pregnant
Have you recently (or ever) had a baby?
Have you ever undergone gynecological surgery (e.g., a hysterectomy)?
Are you an elite athlete (e.g., a runner, gymnast, or trampolinist)?
Do you have a history of lower back pain
Have you ever injured your pelvic region (e.g., through a fall or pelvic radiotherapy)?
Do you experience constipation or regularly strain on the toilet?
Do you have a chronic cough or sneeze (e.g., because of asthma, smoking or hayfever)?
Do you have a BMI over 25?
Do you frequently lift heavy weight (e.g., at work or at the gym)?
Other
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Do you….* This field is required.
Accidentally leak urine when you exercise, play sports, laugh, cough or sneeze?
Need to get to the toilet in a hurry, and do you sometimes not make it there in time?
Constantly need to go to the toilet?
Find it difficult to empty your bladder or bowel?
Accidentally lose control of your bowel, or accidentally pass wind?
Have a prolapse (e.g., a bulge or feeling of heaviness, discomfort, pulling, dragging, or dropping in the vagina)?
Experience pelvic pain or pain during or after sex that involves vaginal penetration
Other
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Your Birth Experience(s)
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Number of pregnancies:
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Birth type (vaginal/assisted/C-section):
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Tearing (degree if known):
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Did your GP clear you for exercise?:
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Other complications if any:
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Have you had your six-week check with your GP?:
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Did your GP recommend any limitations for your exercise?:If yes, what were they?
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Breastfeeding status:
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Current activity level:
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Are you currently taking any medication?
Yes
No
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Do you use or do you have history of using tobacco?
No
Yes
No
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Have you met with any of the following health care professionalsduring or after your pregnancy?
Physiotherapists
Acupuncturists
Chiropractors
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Other (please specify):
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Do/have you experienced any of the following? If so, please providerelevant details (start date, any treatment(s), current status) in thespace provided...
Pain in the central pubic area
Lower back pain or sciatica – location
Neck pain
Coccyx (tailbone) damage or pain
Knee pain
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Any other joint pain (e.g., wrist) – please specify:
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WOMEN’S HEALTH* This field is required.
Heaviness, dragging, or bulging in the pelvic area
Diagnosis of pelvic organ prolapse (uterus/bladder/rectum/vaginal)
Hysterectomy
Leaking urine when you cough/sneeze/exercise
Leaking urine when you cough/sneeze/exercise
Leaking of urine
Difficulty or discomfort with passing urine
Uncontrollable gas
Leaking of feces
Straining during bowel movements (constipation)
Pain in the perineum during sexual intercourse (or any other time)
Unexplained bleeding during or after exercise
Other
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OTHER
Hemorrhoids
Varicose veins
Constipation
Gestational diabetes
Low blood pressure
High blood pressure
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Lifestyle The purpose of the following questions is to help me, as your coach, get a better understanding of your lifestyle. Sleep, nutrition, hydration, and stress all affect your training and recovery. When I have a better understanding of these factors, I can modify your workouts accordingly to ensure you can recover. It also helps us work together to make sure your program leaves you feeling strong and energized. How much sleep do you get in a 24-hour period? How much water do you drink in a 24-hour period? What does your nutrition look like on a “typical” day? Please list meals, snacks, and beverages: Rate your general stress level on a scale of 1–10 (1=little, 10=extreme) Do you feel depressed or anxious, or do you suffer from mood swings? Have you ever been diagnosed with depression or anxiety?* This field is required.
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What are my top tree fitness goals * This field is required.
Describe what would you like to achieve in the Short term 0-3 months )
Describe what would you like to achieve in a medium-term( 3-10 months )
Describe your long-term goal. (6-14monts)
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Free TrialTry my services for free !!
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