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

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 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?

In order to optimise my advice and exercise options for you, I'd love to observe your current posture which can impact on many aspects of physical and emotional wellbeing. If you're happy to, please upload a picture of your posture from the front, side and back wearing tight-ish clothing. All images will remain strictly confidential and will not be shared.

Browse Files

Which services at Willow are you interested in finding out more about?

Online group exercise classes Studio group exercise classes 121 exercise sessions Nutrition Massage/soft tissure therapy Group educational workshops Scar tissue therapy

If relevant, which group exercise class(es) are you interested in?

Core Flow & Stretch Lift HiLo Glow Release Core Restore Not sure

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

I agree

DATA PROTECTION: I understand that Michelle Cornish of Willow Women's Wellness 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 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

Therapist Notes

Willow Studio Core and Pelvic Floor Health Screening Questionnaire

Health Screening Questions