Pre - Assessment
To be completed before your initial consult or class
Name
First Name
Last Name
Date of Birth
Email
example@example.com
Contact Number
Main Reason for Joining Classes
Current Muscle or Joint Problems
Rows
Condition
Time of Onset
Pain Scale 0-10
Any treatment sort
1.
2.
3.
4.
Use this space to include further details from the conditions you described above (if any). You could include aggravating and easing activities, pain description, movement restrictions, professionals involved in your care, etc.
List any Past Surgery
Rows
Surgery
Date
Additional details
1.
2.
3.
4.
Use this space to add further information/surgeries to the above list
List your Current Medications
Birth History (if applicable)
Rows
D.O.B.
Type of Birth
Forceps/Vacuum Used
Baby Birth Wt
Tearing/Episiotomy
Child 1.
Child 2.
Child 3.
Child 4.
Additional Information to Birth History
Pelvic Floor Symptoms
Bladder leakage with cough/sneeze/activity
Bladder leakage assoc with an urge to empty your bladder
Urgency to empty bladder
Feeling of heaviness or dragging vaginally
Pain attempting or during intercourse
Constipation
Urgency to empty bowels
Faecal soiling
Pain in the saddle region
None of the above
Use the space below to add details to any symptoms indicated in the above list.
Do you participate in any form of exercise
YES
NO
Usual Exercise
Rows
Type
No. times/week
Time you have been engaged in this form of exercise
1.
2.
3.
4.
How do you spend most of your time at work (Please tick N/A if not currently working)
Sitting
Standing
Moving
Lifting
N/A
Other
Goals you hope to achieve through classes
Please include at least one goal
Is there any other information you would like to share before starting classes?
Submit
Should be Empty: