Email Address

Age

Time Postpartum

Specify days, weeks, months, or years

Number of Children

Type(s) of Delivery

If so, please explain:

How are you feeling overall?

Are you currently working? If so, what type of work do you do?

Please rate the following statements

Describe your birth experience(s)

Was there any tearing or stitches required? If so, where?

Did your doctor clear you for exercise at your 6-week post-natal check-up? If not, why?

Are you currently taking any medications/supplements? If so, please list:

Do you have any medical or physical limitations?

Please list any conditions that I should be aware of that may limit your ability to participate in an exercise program.

What type(s) and frequency of activity did you engage in prior to becoming pregnant?

What type(s) and frequency of activity did you engage in during pregnancy?

What are your training goals?

How can I help you?

Are you comfortable performing fundamental movement patterns such as squats, lunges, and rows?

Have you sought out treatment for any of these conditions? If so, please elaborate:

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 your bowel movements or urination painful? If yes, please give further details:

Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? If yes, please elaborate:

Do you experience pain with intercourse or sexual stimulation? If yes, please give details:

Do you experience pain inside or at the joints of your pelvis? If yes, please elaborate:

Have you ever had any gynecological surgeries (i.e. hysterectomy, fibroids removal)? If so, please list:

Have you ever had a miscarriage? If so, how many?

Do you have a history of low back pain or other type of back pain? If so, please elaborate:

Do you have, or have you ever had, a chronic cough or a condition that affected your breathing (i.e. smoking, asthma, allergies)? If so, please give details:

Are there any other things I should know about your medical history (i.e. surgeries, cancer, heart conditions)?