"The Leak Proof Pelvic Floor Solution" Screening Form

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Hi and Welcome!
I love that you're here and interested in working with me.

Filling out this form will help me get to know what you need help with and have a better idea if we would be a good fit to work together.
Make sure you answer questions with as much detail as you can so I have some background on any symptoms you're feeling and where you're starting from.

I'll be in touch soon,
Maritza

Email *

Name: *

Age: *

How many kids do you have? How old are they? *

What symptoms are bothering you ? What are you feeling? *

Diastasis Recti ( Abdominal Separation)

Pelvic Organ Prolapse

Leaking when you sneeze or jump

Sore hips or lower back

Heavy feelings in your pelvis

Other:

What have you tried before to fix this and why do you think it didn't help you? *

What's your goal and how will you know you've been successful? *

Do you realize that while I can prescribe a personlized rehab programme for you, you won't see results if you put the work in? *

Do you have at least 15 minutes a day to devote to your core and pelvic floor rehab programme? *

Yes

Other:

Is there anything else you think I should know about you and your symptoms? Do you have any other health issues that might interfere with exercise? *

Send me a copy of my responses.

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