Pelvic Health Background Form Name * First Name Last Name Email * Phone (###) ### #### Date of your most recent Childs birth? * Birth type? * Ex. vaginal, c-section, assisted (forceps, vacuum, etc) Did you have any birth complications? * Have you had your 6 week check-up with your physician and if so have they cleared you for exercise? * Are you currently experiencing any pelvic pain * Ex. Heaviness, pelvic pain, pain around c-section incision, prolapse, urgency to urinate, leaking, pain during intercourse,etc In general, what are your goals for training right now? Rehab & recover from pregnancy & birth Rebuild or improve strength Rebuild or improve aerobic fitness Reduce or prevent aches and pains Improve core & pelvic floor function Feel less stressed or anxious Change body composition Improve or manage my mental health Other Are there any other medical conditions I should be aware of? * Is there anything else you’d like me to know to help support you on your fitness journey? * How did you hear about me? Social Media Friend Family Member Google/Online Followed you from Pelvico Other Thank you!