Prenatal & Postpartum Questionnaire
Hey!
Coach Katt here. Thanks for reaching out to me with interest in online or in person coaching. Are you ready to put yourself first and make your health and fitness a priority? As a mom of 2, I understand the struggle of taking care of those around you before taking care of ourselves. But if we take care of ourselves, it makes taking care of our loved ones so much easier. So let's get started on that!

I’d like you to answer the following questions as open and honestly as you can. There will be no judgement from me and I want to insure you have my trust and support. With the information you provide me, we will come up with a customized plan together (yes I want your input too!) that supports your lifestyle and gets you feeling happier and healthier.

I look forward to joining your fitness journey as your coach, your mentor and your guide.

Yours in health,
Kathryn
Sign in to Google to save your progress. Learn more
What is your name (first & last)? *
How do you like to be contacted? *
Leave your contact information below. *
What is your date of birth? *
MM
/
DD
/
YYYY
Who is your Emergency Contact? Please include name, relationship and phone number. *
What are your favourite things to do with you child/children? If this is your first child, what are you most looking forward to? *
How do you like to spend your free time? (Us moms know that it isn't easy to find "free time," but we've got to do things for ourselves too!) *
Are you currently under a doctor's care? *
If yes, include name and contact information for professionals on your health care team. If no, type N/A. *
When was the last time you had a physical exam? *
Are you currently pregnant? *
Have you been recently hospitalized? If yes, please explain. *
How many pregnancies have you had? *
Have you had any pregnancy complications? Current or past pregnancies. If yes, please explain? *
Have you experienced pregnancy loss? Please provide any details you are comfortable sharing or write NA. *
If you have children, what are the dates of their births? *
What type of delivery(ies) were they? *
Required
Were there any complications or interventions required? *
Describe your birth experience(s). *
Have you been to a Pelvic Floor Physiotherapist during pregnancy, postpartum or recently? If yes, please explain course of treatment. *
Do you have incontinence, prolapse or any pelvic floor dysfunction/symptoms (leaking, pain or discomfort)? *
Do you have or have you been checked for Diastasis Recti? *
Are you currently breastfeeding? *
Did you exercise prior to pregnancy? What did your exercise involve? *
Did you exercise during pregnancy? What did your exercise involve? *
Have you resumed exercise postpartum? What does this involve? *
What are you current health and fitness goals? *
By achieving these goals, how will your life improve? *
Do you have any pain, injuries or exercise limitations? *
On a scale of 1-10 with 1 being almost none and 10 being extremely high, where is your daily stress? What is the cause of the majority of your stress? *
What is the biggest obstacle holding you back? *
If you could see your life one year from now, what would it look like? *
Are you willing, ready and able to invest time, money and hard work to reach your goals? *
On a scale of 1-10 how committed are you to reaching your goals? With 1 being "Can I just stay on the couch?" to 10 being "Can we start right now?" *
My 1-1 coaching starts at $350/month. Are you willing to make that investment right now? *
If we determine that my coaching is the right fit for you, can I celebrate your wins on social media? *
Is there anything else that I, as your coach, should know? *
The information above is true, to the best of my knowledge. Please write your name as an e-signature. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms