Name
Surname
Email
Phone Number
Suburb you live in
Emergency contact name
Emergency contact number
If you would like to share with us, what are your children's names and how old are they? This is for reference use only and will not be used in any form of media.
1b. If you answered yes, how many weeks pregnant are you?
1c. If you are currently pregnant, have you experienced any of the following: Marked fatigue (more than is expected during pregnancy), severe headaches or dizziness, vaginal bleeding/spotting, concerns over over baby's size or position, abdominal pain, problems with cervix (eg. cervical stitch needed), pelvic joint pain, knee pain, incontinence, swelling (hands, ankles, face) or pregnancy induced hypertension?
2. The following information is helpful for us when considering the effects of birth on your pelvic floor and recovery. Please describe what type of delivery you experienced for all of your children. Types of delivery include: Vaginal birth, vaginal birth with intervention (forceps, episiotomy, vacum), planned c-section birth, emergency c-section birth (pushing stage of labour not reached), emergency c-section following the pushing stage of labour. If you have not yet given birth please say so.
3. Did you experience any complications during any of your pregnancies or births?
4. Did you need stitches for vaginal or perineal tearing (not including episiotomy stitches)? If so, and if you can remember, what degree of tear did you experience? Please state N/A if not applicable.
5. If you birthed any of your babies by cesarean section, please tell us if you currently experience pain around the scar area, a lack of sensation around the scar area or a pulling/tugging/tightness sensation around the scar area. Please state N/A if not applicable
6. If you reached the pushing stage of labour and you are able to remember, how long were you pushing for? Please state N/A if not applicable.
7a. Do you currently experience any urinary leakage when jumping, running, high impact activities, coughing or sneezing or any urinary leakage with a feeling of desperation/panic of needing the toilet? If so, please tell us in as much detail as you would like. This information is helpful for us to plan the intensity of impact in your initial training sessions.
7b. Do you currently experience pelvic organ prolapse, a feeling of pelvic floor weakness or a dragging sensation down through your vagina? Please state yes or no, plus any additional information you think will be helpful.
7c. Do you currently experience tummy muscle separation (diastasis recti), a bulging or a ridge popping up in between tummy muscles, or a hernia? Please state yes or no plus any additional information that you think will be helpful.
7d. Do you experience pain with sexual intercourse? Please state yes or no plus any additional information that you think will be helpful.
7e. Carpal tunnel syndrome (inflamed/painful tendons in the wrist), painful pelvis (including pubic bone, sacrum and tail bone/coccyx), painful knees, upper back pain or lower back pain? If so, please tell us more in as much detail as you would like.
8. On a scale of 1 to 10 (10 being very aware), how aware are you of your pelvic floor
If you have seen a women's health physio, please give details of their name and what the outcome of the appointment/treatment was.
10. Is there any other information that you would like to share with us?
11. Have you or do you currently suffer from any any medical condition that may be affected by exercise. If so, please give details
12. Please list any medication you are currently taking (please include non-prescription medication if you have been taking it long term). Please state N/A if not applicable.
13. How much sleep are you getting in an average night? Please tell us if this is usually a block of sleep or broken hours of sleep. Don't worry about exact numbers, it's just an estimate.
14. On average over the past four weeks, how have your stress levels been on a scale from 1-10 (10 being extremely high). Please tell us more about it if you would like to.
15. In order to ensure the best possible support and care during our sessions, we believe it's important to understand and accommodate individual needs. To help us assist you better, please consider sharing any mental health concerns or conditions you feel we should be aware of that will help us support your experience at Strong Mums. This information will remain strictly confidential and will solely be used to tailor our approach for your well-being during the sessions.
I acknowledge that this exercise program/class has been specifically designed for mums including pre and post natal by Strong Mums. In normal circumstances the exercises should not harm me or my baby (if pregnant) in any way. I shall inform Strong Mums of any medical changes prior to commencing any training session. Strong Mums will not be liable in any way for any unforeseen circumstances or for any circumstances of which they should have been aware, but I failed to notify them. I give permission to Strong Mums to contact the emergency contact number I provided should the need arise. I have read this statement and agree to be bound by it and to release Strong Mums from all claims.
Where did you hear about Strong Mums?
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