Willow Studio Core & Pelvic Floor Health Screening Questionnaire

All responses will be treated in strict confidence, held securely (password protected) and will be destroyed after 6 months.

Full Name

First Name Last Name

Mobile Number

Area Code Phone Number

Date of Birth

Date Date Picker Icon

Email

example@example.com

How many years postnatal are you? (if applicable)

Are there any longstanding issues with your pregnancy(ies) or birth(s) that you are still suffering with?

Details of any current exercise.

Has your doctor ever said that you have a heart condition AND that you should only do exercise recommended by your doctor?

Yes No

Do you feel pain in your chest when you do physical activity?

Yes No

In the past month, have you had chest pain when you are not doing physical activity?

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity

Yes No

Is your doctor currently prescribing drugs for your blood pressure or heart condition?

Yes No

Are you diabetic?

Yes No

Are you experiencing difficulty with your bowel, wind or urinary urges?

Yes No

Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly?

Yes No

Are your bowel movements or urination painful?

Yes No

Do you experience a feeling of heaviness in your pelvis? Or has anyone ever suggested you may have a prolapse?

Yes No

Do you currently or have you ever needed to wear incontinence pads?

Yes No

Do you experience pain inside or at the joints of your pelvis?

Yes No

Are you going through or have you been through the menopause?

Yes No

Have you ever undergone any gynaecological surgery (e.g. hysterectomy, fibroids removal)?

Yes No

Are you or have you ever been an elite athlete? Runner, gymnast, trampolining or any sport that involved regular contact?

Yes No

Do you have a history or low back pain or any other type of back pain?

Yes No

Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx?)

Yes No

Do you suffer from constipation or regularly strain on the toilet?

Yes No

Do you have a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?)

Yes No

Are you or have you been overweight?

Yes No

Do you frequently lift heavy weights (Gym, work, children, caring for disabled or elders?)

Yes No

Are you incontinent overnight?

Yes No

Please provide any further information related to the above issues here, if applicable.

Do you know of any other reason why you should not do physical activity?

Yes No

What are your goals for participating in exercise?

What liquids do you drink during the course of the day and how much of each type?

How is your health in general? Do you need to tell me about any other health issues you may have? Are you on any special kind of medication?

STAYING IN CONTACT: I understand and agree that Michelle Bailey of Willow Studio may contact me by email to send reminders of classes or for other general messages pertaining to Willow Studio services.

I agree

CANCELLATIONS: I understand that quite often there is a waiting list, so my place in my chosen Willow class will be cancelled if I don't attend for three consecutive weeks (unless prior notice given to Michelle).

I agree

DATA PROTECTION: I understand that Michelle Bailey of Willow Studio will hold my personal information (including responses on health questionnaire) securely (password protected) and will not share this with any third parties without my prior consent. If at any time I do not wish my details to be held and no longer wish to use Willow Studio services, I can requested for my personal information to be carefully destroyed. I also understand that by registering for Willow Studio services, my name and email will be added to an email mailing list where occasional emails will be sent relating to services, news, offers and relevant blog articles. My email will not be shared with any third parties and I can unsubscribe from this mailing list at anytime.

I agree

Willow Studio Core & Pelvic Floor Health Screening Questionnaire

Health Screening Questions