Women's Health Screening Questionnaire

Women's 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 NameLast Name
Mobile Number

Area CodePhone Number
Date of Birth

DayMonthYear
Date
Email
example@example.com
How many years postnatal are you? (if applicable)
If applicable, are there any longstanding issues with your pregnancy(ies) or birth(s) that you are still suffering with, physically or emotionally? Please include any details on complications, issues experienced during pregnancy and births, including perineal tears, episiotomy.
Details of any current exercise plus any past activity you enjoyed/would like to take up again.
Health Screening Questions
Has your doctor ever said that you have a heart condition AND that you should only do exercise recommended by your doctor?

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

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

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

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

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

YesNo
Are you diabetic?

YesNo
Are you experiencing difficulty controlling bowel movements, wind or urinary urges?

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

YesNo
Are your bowel movements or urination painful?

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

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

YesNo
Do you experience pelvic pain e.g. lower back, vaginal area, ower abdomen/ pelvis?

YesNo
Are you going through peri-menopause, or are you post-menopause?

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

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

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

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

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

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

YesNo
Are you or have you been overweight?

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

YesNo
Are you incontinent overnight?

YesNo
Do you experience pain that is unrelenting, even overnight?

YesNo
Please provide any further information related to the above issues here, if applicable.
Are you currently undergoing or previously undergone treatment for cancer?

YesNo
What part of your physical or mental wellbeing are you most motivated on improving right now?
What liquids do you drink during the course of the day and how much of each type?
How would you describe your current diet? Include any regular cravings you have.
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?
Which services at Michelle Brown Women's Wellness are you interested in finding out more about?

Online group exercise classesIn person group exercise classesFace-to-face personal trainingRemote/online personal training/coachingNutritionMassage/soft tissure therapyGroup educational workshopsScar tissue therapy
STAYING IN CONTACT: I understand and agree that Michelle Brown may contact me by email to send reminders of classes or for other general messages pertaining to Michelle Brown Women's Wellness services.

I agree
DATA PROTECTION: I understand that Michelle Brown 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 Women's Wellness services, I can requested for my personal information to be carefully destroyed. I also understand that by registering for Michelle Brown Women's Wellness 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
Therapist Notes
Should be Empty:

Women's Health Screening Questionnaire

Health Screening Questions