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Core and Pelvic Floor Health

How strong and functional are your core and pelvic floor?

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Question 1 of 12

What is your full name and date of birth?

Question 2 of 12

Currently pregnant?

If "yes", what is your expected delivery date?

Question 3 of 12

Number of Pregnancies,

And date(s) of delivery.

Question 4 of 12

Delivery Type

(Select all that apply)
A

Vaginal

B

Assisted (Forceps/Vacuum)

C

C-Section

Question 5 of 12

Current Activity Level:

A

Sedentary

B

Lightly Active

C

Moderately Active

D

Very Active

Question 6 of 12

Have you ever seen a Pelvic Floor Physical Therapist?

If "yes", How long ago and what was the outcome?

Question 7 of 12

Do/Have you experienced any of the following:

Musculoskeletal - 

(Select all that apply)
A

Diagnosis of Diastasis Recti?

B

Bulging/doming along the midline of your abdomen?

C

Difficulty with abdominal exercises such as planks or sit-ups?

D

Feel unsupported through your core?

E

None of the above

Question 8 of 12

Do/Have you experienced any of the following:

(Select all that apply)
A

Pain in central pubic area?

B

Low back pain or sciatica?

C

Neck Pain?

D

Hip Pain or Hip Bursitis?

E

Coccyx damage or pain?

F

Knee Pain/Patella Fermoral Syndrome?

G

IT band issues?

H

Chronic Groin Strains?

I

None of the above

Question 9 of 12

Do/Have you experienced any of the following:

Women's Health - 

(Select all that apply)
A

Heaviness, dragging or bulging in the pelvic area?

B

Diagnosis of pelvic organ prolapse?

C

Hysterectomy?

D

Leaking urine when you cough/jump/sneeze?

E

Strong, sudden urge to urinate?

F

Difficulty voiding urine or feces?

G

Uncontrollable gas or leaking feces?

H

Pain or difficulty with intercourse?

I

None of the above

Question 10 of 12

How much sleep do you get in a 24 hour period?

Question 11 of 12

Rate your stress on a scale of 1-10 (1=little, 10=extreme)

Question 12 of 12

Any additional comments you would like to add?

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