STRONG MUMMA HEALTH FORM

STRONG MUMMA Health Form

Please be assured that all the information provided on this form will be kept confidential.
Full Name *

First Name Last Name
E-mail *
example@example.com
How many weeks or months postnatal are you? (please state weeks or months in your answer) *
Have you had your postnatal health checkup with your GP/Doctor?

Yes No This is not an option for me
Has your GP/Health Care Provider advised you are safe to exercise?

Yes No n/a

Birth Information - Please select all that apply

Please Select All That Apply

Episiotomy / painful perineum or tears

Stitches present

Traumatic vaginal birth

C-section

None of the above

Health Overview - Please select all that apply *

Please Select All That Apply

***** NONE / NOT APPLICABLE *****

Shortness of breath

Asthma

Seizures

Heart disease

Eating disorder

Gestational diabetes

Chest pain

Carpal tunnel syndrome

Varicose veins

Joint or muscular pains

Low or high blood pressure

Dizziness

Separation of abdominal muscles / Diastasis

Symphysis Pubis Dysfunction

Sacrum or Sacroiliac Joint Pain

Heavy Leakage of Urine

Persistent bleeding

Pelvic Floor Pain

Sign of Infection

Poor healing

Pain - abdominal, pelvic, back or other

Excessive fatigue

Increased pelvic pressure

Painful breasts / breast abscess

Breast discomfort

***** NONE OF THE ABOVE *****

For anything selected above please provide further details and whether it is past or current:

Pelvic Floor - Please select all that apply

Please Select All That Apply

Do you leak urine control when laughing, sneezing, coughing, jumping or moving quickly?

Are your bowel movements or urination painful?

Do you feel any pressure in your vagina or rectum?

Do you experience pain with intercourse or sexual stimulation?

Do you currently or have you ever needed to wear incontinence pads?

Do you suffer from constipation or regularly strain on the toilet?

NONE OF THE ABOVE

On a scale of 1-10, how much are you troubled by your pelvic floor / continence issues?

	1	2	3	4	5	6	7	8	9	10

1 is A Little, 10 is Very Concerned

Where did you hear about STRONG MUMMA *
Would you like to be added to my weekly mailing list? (workout tips, recipes etc) *
Declaration
If you selected YES to one or more condition in the health overview section

Talk to your healthcare provided by phone or in person and talk with them about the kind of activity you wish to participate in and always follow their advice.

Declaration

I confirm that I have read, understood and accurately completed this questionnaire, consulted with my GP if necessary and that it is my responsibility to ensure the safety of myself when participating in any of the exercises.

This program is not intended to diagnose or treat any illness or injury. It is for educational purposes only. If you choose to try any of the exercises presented here you do so at your own risk. Please consult your health care provider before you start any new program.
Full Name *

First Name Last Name
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STRONG MUMMA Health Form

Declaration