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.
Name or Nickname
Email address
Country
Age
SYMPTOMS AND HISTORY
Primary Symptoms of Concern*

Erectile DysfunctionHard FlaccidHourglassingGenital Numbness/Tingling/Loss of pleasure/orgasmGenital Pain/Testicle Pain/Ejaculation PainGenital Discoloration/Shape changesUrinary UrgencyUrinary/Bladder BurningUrinary Hesitancy/Incomplete evacPost Urine DribbleRectal Tightness/Fullness/Incomplete EvacuationRectal PainRectal incontinence (leakage)Chronic ConstipationOther
How long have you been experiencing these symptoms?
No.* *
List what you believe CAUSED your symptoms to start:*
List any remedies, activities or treatments that HELP your symptoms:*
List any remedies, activities or treatments that WORSEN your symptoms:*
List any diagnostic testing, procedures, surgeries, injections, prior injuries, traumas, complications, or any other information you feel is necessary to share. *
Have you had a prostate exam, or lab tests to rule out infection:*

YesNo
List any current medications or supplements you are taking:*
List any of the following that you regularly use:*

THC productsAlcoholOpiodsSSRI'sNoneOther
SEXUAL HISTORY
Masturbation/Sexual Encounter frequency:*

DailyWeeklyMonthlyRarely/Never
Pornography frequency:*

DailyWeeklyMonthlyRarely/Never
Have you ever regularly practiced "edging" (stimulating to the point of climaxing, stopping then restarting)?*

YesNo
Have you ever practiced "Jelching" (pulling on the penis to extend/lengthen it)?*

YesNo
Any history of sexual trauma/abuse?*

YesNo
Any history of injury to the back, hips, legs, genitals or groin?*

YesNo
FUNCTIONAL/MUSCULOKELETAL
Rate your CORE/ABDOMINAL strength:*

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1 is Very Weak, 10 is Very Strong
Rate your GLUTE MUSCLE strength:*

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1 is Very Weak, 10 is Very Strong
Rate your FLEXIBILITY:*

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1 is Very stiff/rigid, 10 is Very flexible
Rate your ACTIVITY LEVEL:*

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1 is Sedentary, 10 is Very active
Rate your POSTURE*

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1 is Problematic, 10 is Ideal
How many hours do you SIT per day?*
How many hours do you STAND per day?*
How many hours do you spend GAMING per day?*
DIETARY
How many BOWEL MOVEMENTS do you have per day/week?*
Rate the QUALITY of your DIET:*

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1 is Poor (processed/fast food), 10 is Clean eating (lean meats, fruits/vegs)
PSYCOLOGICAL
Rate your AVERAGE level of ANXIETY/STRESS:*

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1 is Calm - not anxious, 10 is Very anxious
Rate your ANXIETY/STRESS LEVEL when SYMTOMS FLARE:*

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1 is Calm - not anxious, 10 is Very anxious
ALMOST DONE...
List any other information you would like to share before our session:*
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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Coaching Intake Form

SYMPTOMS AND HISTORY

SEXUAL HISTORY

FUNCTIONAL/MUSCULOKELETAL

DIETARY

PSYCOLOGICAL

ALMOST DONE...