Health Screening Form Pre-screening form for exercise classes. Name* First Name Last Name If you are early postnatal, have you had your 6-week check?*YesNoYour D.O.B DD MM YYYY Email* Mobile Number*Are you experiencing difficulty with your bowel, wind or urinary urges?*Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly? Or leak without warning?*Are your bowel movements or urination painful?* If so please give detailsIs there any blood present in either your stools or urine?* Do you experience any urinary hesitancy, starting/stopping of your urine stream or incomplete emptying?*Do you often think you need to go to the toilet to urinate - 'just in case'?*Do you lack the ability to hang on if you have to urinate or have a bowel movement?*Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Has anyone ever said you may have a prolapse?*Do you currently or have you ever needed to wear incontinence pads?*Do you experience pain in your genitals and/or pelvis with or without sexual intercourse?*Do you experience pain inside or at the joints of your pelvis?*Are you currently pregnant?*Have you recently (or ever) had a baby? If yes, please state how you gave birth in the section below. (Vaginal, c-section, episiotomy, forceps, labour length etc*If Post Natal, are you still breastfeeding?Do you have separation of your abdominal muscles at the midline (Diastasis)?Have you had or do you still have varicose veins?Do you have any problems wearing or inserting tampons?Did you develop excessive stretch marks in pregnancy?*Are you hypermobile?*Are you going through or have you been through the menopause?*Have you ever undergone any gynaecological surgery (eg. hysterectomy, fibroid removal etc)?*Have you ever suffered with any bowel conditions such as IBS, Colitis or are you a Coeliac?*Are you or have you ever been an advanced recreational or professional athlete? Runner, gymnast, trampolining or any sport that involved regular contact or blows to your abdomen?*Do you have a history of low back pain or any other type of back pain?*Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx)?*Do you have a DAILY bowel movement? Do you suffer from constipation or regularly strain on the toilet? Do you need to assist your own voiding?*Do you or have you ever had a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma)?*Are you or have you ever been overweight?*Do you frequently lift heavy weights (gym, work, carer, children)?*Are you incontinent overnight or wake in the night often to urinate?*Are you on any medication?*Do you suffer any other medical conditions?*Have you had any major surgery or trauma to your body?*Does your work / daily activity involve lots of sitting, walking or lifting?*Have you ever been diagnosed with a Thyroid issue or taken any Thyroid medication?*Do you have any intolerances/allergies?*Do you take any hormone correction medication?*Do you have either Type 1 or Type 2 Diabetes?*Do you add sugar to your food or drink?*Are you on a special diet ie., vegetarian/vegan?*Are you taking any supplements currently?*Very flexible or unstable joints?*Early onset of Advanced Osteoarthritis?*Chronic degenerative joint disease?*Tearing of tendons or muscles?*Weak muscle tone?*Osteopenia (low bone density)?*Deformities of the spine?*Flat feet?*Temporomandibular Joint Syndrome (spontaneous locking/unlocking of jaw bone)?*Short-sightedness?*Abnormal/poor/slow wound healing and/or poor scar formation?*Please use this space if you have ever given birth. Please give full details of how (Vaginal, c-section, episiotomy etc)On a scale of 1-10, how much are you troubled by your Core/Pelvic Floor issues? 1 = "a little" 10 = "very concerned"*On a scale of 1-10, how would you rate your day-to-day life stress levels? 1 = "not stressed" 10 = "very stressed"*In your own words - what is/are the problems? What are your reasons for seeking help via this programme? Please detail any previous attempts to improve your situation*What liquids do you drink during the day and how much of each type? How much alcohol do you drink per day?*Data Protection. Your form will be kept on your instructor's private computer for 5 years. All information provided will not be shared to any 3rd party and will only be shared with Burrell Education if your instructor needs a 2nd opinion. Please tick if you agree with this.* I Agree Please confirm that you are happy to receive my email newsletter with information about my classes and news about women's health and fitness.* Yes, I do want to receive your email newsletter No, I do not want to receive your email newsletter CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.