Name *
Name
Phone
Phone
Specify days, weeks, months, or years
Any Complications?
Please rate the following statements
My energy level is excellent
My energy level is excellent
My stress is low
My stress is low
My mood is excellent
My mood is excellent
My sleep quality is excellent
My sleep quality is excellent
Are you currently:
Please list any conditions that I should be aware of that may limit your ability to participate in an exercise program.
How can I help you?
Please indicate if you currently have, or have ever had, any of the following:
If you are experiencing incontinence (leaking urine or feces), pain in the pelvic region, feel pressure in the rectum or vagina, or suspect you may have an abdominal separation (called Diastasis Recti), please answer the following questions:
Are you experiencing difficulty with your bowel, wind, or urinary control?
Please check all that apply:
Do you lose urinary control when laughing, sneezing, coughing, jumping, or moving quickly?
Please check all that apply:
Have you been told you have (or checked yourself for) a separation of your abdominal muscles at the midline?
This is a very common condition called Diastasis Recti.
Are you going through, or have you gone through menopause?