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 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 81198Δ
