PELVIC FLOOR AND CORE PROGRAM

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Email *

First and Last Name *

FOR FEMALES: Are you pregnant?

Yes

Maybe

N/A

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FOR FEMALES: If you just had a baby, are you more than 8 weeks postpartum?

Yes

N/A

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Check off the boxes that are applicable. *

Flat Feet

High Arch

Plantar fasciitis

Increase symptoms of PMS for women; periods are heavy and then stop, or almost stopped on the 4th day, only to start flow again on the 5th or 6th day

Diastasis

Pain in the upper back or neck for no apparent reasons

Pain in Lower Back

Right Hip Pain

Left Hip Pain

Right Knee Pain

Left knee Pain

Hyperlordosis

Bleeding Uterus Fibroids

Visible Rectal Prolapse

Visible Uterus Prolapse (have to tuck in your uterus/bludder after peeing)

Have troubles to urinate

Inguinal Hernia

Abdominal White Line Hernia

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Comments, questions, concerns

Why are you interested in this program? *

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