• monica halper

    thoughtful movement

    www.thoughtfulmovement.com

    thoughtfulmovement@gmail.com

    07983525320

  • Postnatal or Scar Therapy Health History

    Please fill in the form below as soon as possible. Thank you so much!
  • Are you booking in for a specific modality?
  • Your Date of Birth (the year is sufficient)
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  • If you have a scar, are you comfortable touching it?

  • Are you currently pregnant? If yes, how many weeks?

  • Have you ever undergone IVF treatment?

  • Do you know if you have a separation of your abdominal muscles at the midline? (Diastasis Rectus)

  • Are you experiencing difficulty with your bowel, wind or urinary urges?

  • Do you lose urinary control when laughing, sneezing, coughing, jumping or moving quickly?

  • Are your bowel movements or urination painful?

  • How often do you have bowel movements?

  • Do you experience a sensation of pressure in your vagina or rectum or notice any protrusions from your orifices? Has anyone ever suggested you might have a prolapse?

  • Do you experience pain in your genitals with or without sexual intercourse?

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

  • Do you experience pain with intercourse or sexual stimulation?

  • Do you currently or have you ever needed to wear incontinence pads? If so, when and how many did you need in a day?

  • Do you experience pain inside or at the joints of your pelvis?

  • Have you ever undergone any gynaecological surgery? (Laparoscopy, fibroids removal, endometriosis treatment, hysterectomy or other?)

  • Are you going through perimenopause or menopause? If yes, when did it begin?

  • Are you or have you ever been an elite athlete? If so, which sports or activities, for how long and at what age(s)?

  • Do you have low back pain or other back pain?

  • Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or coccyx injury?)

  • Do you wake in the night to urinate?

  • Do you experience any of the following during sleep?
  • Are you incontinent overnight?

  • Do you have a chronic cough or a condition that affects breathing? (Hayfever, asthma?)

  • Are you or have you been overweight?

  • Do you have or have you had a hernia? If yes, what type?

  • Do you have any surgical mesh implants?

  • Do you frequently lift heavy weights? (in the gym, on the job, children, caring for disabled or elders?)

  • Do you smoke?

  • How many units of alcohol to you consume?
  • Do you have:
  • Do you take any medications or supplements? Please list medication names.

  • Do you have pain in any of these areas? (you can tick all that apply!)

  • 1. Thank you so very much for your trust; I look forward to working with you!

    2. I am GDP compliant and your data will not be given to any other parties without your express permission. The above information is solely for the purpose of providing you with the best service and the data will be deleted before long. The more I understand about your physical history, the better chance we have of achieving your goals!

    3. Remember to bring cash or pay by BACS prior to your session. Please note I must request payment in full for appointments canceled with less than 24 hours notice.

    4. I am not a licensed massage therapist or licensed medical professional; therefore I will not be treating, diagnosing, rehabilitating or prescribing information to treat any disease or injury. As a certified fitness professional, I will be assessing movement, muscle function, body composition, current capabilities and lifestyle obstacles to ensure I deliver effective and competent exercise programming. I may have to apply touch to correct your form, locate a muscle that is not firing effectively and/or to guide movement. If at any time this makes you feel uncomfortable, please make me aware and your personal wish will be respected immediately.

    Please sign here to acknowledge, then Submit your form and I will be in touch!

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