Postnatal/Reconnect & Thrive form

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal Code

What is your occupation?

Have you or anyone in your household ever been diagnosed with Covid 19?

Have you or anyone in your household shown any symptoms of Covid 19 in the last 7 days?

Have you or anyone in your household been advised by the government as being clinically vulnerable and to shield?

Have you recently travelled abroad? If so, where and when did you return?

Have you noticed any new rashes on your feet or body?

Please contact me immediately if you or anyone in your household develops symptoms associated with Covid 19 within 7 days of the treatment. Please tick to mark your agreement

Have you had any unusual leg cramping?

If anything changes between now and your appointment date, please inform me asap. Please tick to confirm you have read this and will contact me if so

Date of your last delivery? How Postnatal are you?

How many children do you have and what are their ages?

Types of delivery with each birth (assisted, vaginal, c section, tearing, episiotomy)

How was your 6 week check up?

Are you breast or bottle feeding? If breast are there any issues I should be aware of before massage/Exercise?

Are you still bleeding post birth? Have your periods returned?

History of previous pregnancies

History of labour

How is your postnatal healing going? Have you experienced any complications or set backs?

Are you seeing or have you seen any other professionals for your postnatal health and recovery? (Chiro, osteo, GP, midwife)

Please tick all that apply

Details of anything ticked above

How would you describe your pelvic floor health? Do you have a prolapse or pressure in the vagina/rectum? Do you leak urine when you exercise, laugh, sneeze, cough? Do you find it hard to hold in gas?

Is there anything else you think I should know?

Has your doctor ever advised you that you have a heart condition?

Are you undertaking any forms of exercise? If yes, what?

How would you rate your stress levels out of 10? 10 being very stressed

How would you rate your emotional health out of 10? 10 feeling very emotional

How would you rate your fitness levels out of 10? 10 being very fit

For Therapist to fill out:

Informed consent

I declare that the information I have given is correct, and as far as I am aware I can undertake this treatment/session. I also confirm that I have not withheld any information which maybe relevant to my undergoing any treatment/Exercise.

Exercise

Please consult your GP or women’s health physiotherapist before you embark on any exercise. Drink lots of water or an isotonic drink before, during and after working out. Please wear comfortable clothing that will enable you to exercise without restrictions.

Massage

I will inform Tanya if there is anything I don’t feel happy with or I find uncomfortable.

Informed consent

I would like to be added to the emailing list for newsletters, updates and offers