Health Pre-Screening Form Health Pre-Screening Form Pre-screening form for exercise classes. Name* First Name Last Name If you are early postnatal, are you at least 6 weeks post birth?* Yes No Your D.O.B Day Month Year Email* Mobile Number*Are you experiencing ANY urinary or faecal leaking? If so please say when and how often.*Do you suffer from constipation? If so are your bowel movements painful?*Do you notice you stop/start when urinating? Do you ever feel like you haven’t completely emptied your bladder?* If so please give detailsIs sex uncomfortable or painful?* Do you have or have you had any lower or upper back pain? Or have you had any pelvic pain?*Have you ever had a baby? If so please write the details of when, if it was a CSection or emergency C section. If it was a vaginal delivery did you have any tears/episiotomy or assistance.*Do you have a diastasis / midline gap in your tummy? Have you seen anyone about it?*Are you going through the peri / menopause ? Or have you noticed any changes in your periods?*What exercise have you done in the past? Are you exercising now and if so what and how regularly?*How is your eating and drinking? Are you following any specific diet? Do you drink much caffeine or alcohol? How much water do you generally drink during the day?*Do you feel stressed in your everyday life? Can you tell me between 1 – 10, where 10 is VERY stressed.*Finally – Any other information?? Why have you got in touch with me and what are the main issues you would like to sort out?*Thank you so much for taking the time to fill this form out. It will help me understand what you have been through and how I can help you.Data Protection. Your form will be kept on my private computer for 5 years. All information provided will not be shared to any 3rd party, unless you have agreed . Please tick if you agree with this.* I Agree Cancellation Policy for 1:1 sessions: Please let me know if you need to cancel our 1:1 session as soon as it is conceivably possible so that I can open it up to others. Sessions cancelled within 24 hours will forfeit the session cost. Outside of 24 hours we will try and rebook the session at a mutually convenient time if possible, or hold that session in credit.* I Agree Consent*I am committed to protecting and respecting your privacy, and I’ll only use your personal information to communicate with you about my services and to provide information on women's health and fitness. You can unsubscribe at any time. Visit my privacy policy for further information. I agree to be contacted. CAPTCHA Δ
