Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Screening Form

Hi Mama,

I am beyond excited to start working with you! Before we jump into it all, I would love to learn more about YOU, exercise and health history, goals and medical. This is to ensure I can give you the best possible service, personalise it to your needs and desires and most importantly that you achieve what you set out to do...

If you can take 5-10 minutes to fill this in as much details as possible, I would be so very grateful

Xx Tammy

Director Flos Motherhood

Full Name: *

Email Address: *

Date of Birth

Full Address Please

How did you find out about our Flos Motherhood Programs, If someone referred
you - let us know who it was :)

Are you currently *

TTC - Trying to conceive

Postpartum

Beyond 1 year postpartum

Kiddies at school

Postnatal Mummies - How many kiddies do you have and how old?

If you already have kids or have previously delivered, how did you give birth?

Vaginal Delivery

Vaginal with some intervention (such as forceps, episiotomy, ventouse)

C-section

both or combination

Clear selection

How are you feeling energy wise currently? *

Exhausted

Very energised each day

Have you been exercising lately? *

Yes

Occasionally

Not really

If you have been exercising - how frequently? *

5-7x per week

3-5x per week

1-2x per week

Not very consistently

What are you struggling with the most at the moment mama? *

How do you want to feel and be living your days? *

Please tick if any of the following applies to you (provide details where
necessary). If you place a tick (ie yes) against any question, you will require a
doctor’s clearance. *

High blood pressure

High cholesterol/triglycerides

Pain/tightness in chest

Rheumatic fever

Any heart/stroke condition

Diabetes (Type 1 or 2)

Epilepsy

Pounding/palpitating heart

Back or muscular pain

Spinal/disc condition

Arthritis

Breathing difficulties or asthma

Hernia

Regular headaches or migraines

Depression

NO MEDICAL CONDITIONS

Required

List Prescribed Medication (eg: Aspirin, Anti Depressants, Blood Pressure Medication
etc) *

List any other injuries or conditions

Pelvic Health Assessment *

Do you accidentally leak urine when you exercise, play sport, laugh, cough or sneeze?

Do you need to get to the toilet in a hurry - or not make it there in time?

Do you constantly need to go to the toilet?

Do you find it difficult to empty your bladder or bowel?

Do you have a prolapse (e.g. a bulge or feeling of heaviness, discomfort, pulling, dragging or dropping in the vagina)?

Do you suffer from pelvic pain or experience pain during or after intercourse?

Do you lift heavy weights frequently?

Do you suffer from constipation?

I don't experience any of the above

Required

What was the main reason you have signed up? what do you want to achieve during this program and how do you want to feel at the end?

Any other questions or info please let me know here.. Thankyou so much for your time and I cannot wait to get started working together

Xx Tammy

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Tammy Obst. Report Abuse

Forms