Monica Halper - Natal Client Questionnaire Form

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!
Today's Date*
Are you booking in for a specific modality?

Natal WellnessMELT MethodPilatesYogaNKTAbdominal Scar TherapyI'm not sureWhatever it takes
Full Name*

PrefixFirst NameLast Name
Your Date of Birth (the year is sufficient)

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
For home visits ONLY: How to find you? (Please include relevant information as to how to find or access your space. Thank you!)
Mobile Number*

Country CodeArea CodePhone Number
E-mail*
How did you find me?
Emergency Contact
Emergency Contact Name

First NameLast Name
Phone Number

Country CodeArea CodePhone Number
How many pregnancies have you had?
How many births have you had?
Date of your most recent delivery?
Type of deliveries, most recent and previous (Vaginal/Assisted/Epidural/C-Section)
If vaginal, did you have an episiotomy or tearing? What Grade of Tearing?
Can you describe your delivery/deliveries? (Easy, challenging, painful, quick, long, arduous, traumatic or any other adjective that springs to mind...)
Have you had your 6-8 week Post Natal Check up? When? What was the outcome?
Did you experience pudendal or pregnancy related nerve damage? Is it still present?
Post Natal bleeding status? If you're still bleeding is it light, heavy, thick, thin, smooth or clotted?
What is your breastfeeding status? Did you? Are you still? Were there complications?
If you have a c-section scar(s), do you still experience any sensations from the site of incision or any sensation you feel is related? Does your scar appear to be healed?
If you have a scar, are you comfortable touching it?

YesNoOther
Has your menstrual cycle resumed? Is it regular or erratic?
Are you currently pregnant? If yes, how many weeks?

YesNoOther
Have you ever undergone IVF treatment?

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

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

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

YesNoOther
Are your bowel movements or urination painful?

YesNoOther
How often do you have bowel movements?

Twice daily or moreOnce dailyOnce every other dayLess than 3 times per weekOther
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?

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

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

YesNoOther
Do you experience pain with intercourse or sexual stimulation?

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

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

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

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

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

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

Yes, in the pastYes, currentlyOnly occasionallyNoOther
Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or coccyx injury?)

YesNoOther
Do you wake in the night to urinate?

Not usually1 time2 times3 or more timesOther
Do you experience any of the following during sleep?

SnoringTeeth GrindingSleep ApneaNone that I'm aware of
Are you incontinent overnight?

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

YesNoOther
Are you or have you been overweight?

Yes, in the pastYes, currentlyI'm a yo-yoNoOther
Do you have or have you had a hernia? If yes, what type?

Yes, in the past but now resolvedYes, currentlyInguinalFemoralUmbilicalHiatalIncisionalEpigastricNoOther
Do you have any surgical mesh implants?

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

YesNoOther
Do you smoke?

YesNoOther
How many units of alcohol to you consume?

None1-3 Monthly1-3 weekly4-6 weeklymore than that!
Do you have:

High Blood PressureAnemiaDiabetesOsteoporosis/penia
Do you take any medications or supplements? Please list medication names.

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

neckshoulder/supper backmid backribsbreastselbow/scarpal tunnel/wristsbelly/abdomensacrumsciatic/hip/buttockknee/sachilles/calvesankle/sfeet
Do you participate regularly in any movement or sports activities? How often do you or how often would you like to? Please tell me what you enjoy? (Yoga, Pilates, Running, Gym classes, Crossfit, Walking, Tennis, Dancing, etc?)
Please describe any particular position or action you do on a regular basis. Does this position or movement cause you noticable discomfort? (Such as specific movements required to perform your job or sitting at a desk all day.)
Please describe briefly any pertinent details about your diet and nutrition? (Vegetarian, vegan, gluten-free, other special diets, well balanced, lots of sugar?)
What liquids do you drink during the course of your day and how much?
Have you seen a Womens Health Physio or other physio for any of the issues noted above? Are you currently being treated?
Please tell me anything you'd like to note or any concern you have, whether it is related to pelvic floor, continence, your c-section scar, your belly or your health in general.
What is your top priority or your overall or long term goal for our session(s)?*
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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Postnatal or Scar Therapy Health History