UnbrokenPelvis Coaching Intake Form

  • Coaching Intake Form

    All answers are private and confidential, and will assist to get a better understanding of your unique history, lifestyle and symptoms in order to develop a personalized recovery strategy.   Please understand I am not a licensed medical professional, and I am simply offering recovery strategies based on my own unique experiences in personally recovering from pelvic floor dysfunction.  My goal is to assist you in identifying root causes and contributors to your dysfunction as we work to develop a plan of action for recovery.  Please complete the below to the best of your ability.  

  • SYMPTOMS AND HISTORY

  • Primary Symptoms of Concern*

  • How long have you been experiencing these symptoms?    
     *    *      

  • Have you had a prostate exam, or lab tests to rule out infection:*
  • List any of the following that you regularly use:*

  • SEXUAL HISTORY

  • Masturbation/Sexual Encounter frequency:*
  • Pornography frequency:*
  • Have you ever regularly practiced "edging" (stimulating to the point of climaxing, stopping then restarting)?*
  • Have you ever practiced "Jelching" (pulling on the penis to extend/lengthen it)?*
  • Any history of sexual trauma/abuse?*
  • Any history of injury to the back, hips, legs, genitals or groin?*

  • FUNCTIONAL/MUSCULOKELETAL

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  • DIETARY

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  • PSYCOLOGICAL

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  • ALMOST DONE...

  • Liability Disclaimer:

    By submitting this form, you acknowledge that the information provided is true and accurate to the best of your knowledge. You understand that the services provided by the provider are not a substitute for professional medical advice, diagnosis, or treatment. The provider is not liable for any decisions made based on the information provided or any outcomes resulting from the services received. You agree to release and hold harmless the provider from any and all liability arising from your use of these services.

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