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Pelvic Health & Core Pre-Screening Questionnaire

Every woman is unique and your Core/Pelvic Health and/or incontinence issues will have their own unique origins. In order for us to assess whether this programme is right for you, we’d like you to assist us by answering the following questions as fully as possible. The answers you provide will help us to help you. Thankyou.

Holistic Core Restore® © Burrell Education 2012

The information that you provide will remain COMPLETELY CONFIDENTIAL. You will receive a copy of your answers as will your Coach, the creator of the programme, Jenny Burrell and our clinical consultant Michelle Lyons. This ensures that we can thoroughly assess your suitability for the programme and if further help is required outside the scope of exercise we can also assist you in finding this help. Please rest assured that the information you provide on this form WILL NEVER BE SHARED. Your privacy is extremely important to us.

PLEASE NOTE:
Please ensure you answer ALL questions. Upon successful completion of this form, you will receive a confirmation message AND a copy of your answers to the email address given. If you DO NOT receive these, your submission has NOT been successful.

Name *
Name
If you are early Post Natal, have you had your 6-8 week check? *
Date of Birth *
Date of Birth

Your coach is Karin Goldschmidt

Please answer yes or no to the following questions.
Answer YES even if you only partially agree with the statement. Then use the space below to give further details.
1) Are you experiencing difficulty with your bowel, wind or urinary urges? *
2) Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly? Or leak without warning? *
3) Are your bowel movements or urination painful? *
4) Is there any blood present in either your stools or urine? *
5) Do you experience any urinary hesitancy, starting/stopping of your urine stream or incomplete emptying? *
6) Do you often think you need to go to the toilet to urinate - 'just in case'? *
7) Do you lack the ability to hang on if you have to urinate or have a bowel movement *
8) Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Has anyone ever said you may have a prolapse? *
9) Do you currently or have you ever needed to wear incontinence pads? *
10) Do you experience pain in your genitals and/or pelvis with or without sexual intercourse? *
11) Do you experience pain inside or at the joints of your pelvis? *
12) Are you currently pregnant? *
13) Have you recently (or ever) had a baby? If yes, please state how you gave birth in the section below. (Vaginal, c-section, episiotomy, forceps, labour length etc *
14) If Post Natal, are you still breastfeeding? *
15) Do you have separation of your abdominal muscles at the midline (Diastasis)? *
16) Have you had or do you still have varicose veins? *
17) Do you have any problems wearing or inserting tampons? *
18) Did you develop excessive stretch marks in pregnancy? *
19) Are you hypermobile? *
20) Are you going through or have you been through the menopause? *
21) Do you currently or have you ever suffered with cystitis? *
22) Have you ever undergone any gynaecological surgery (eg. hysterectomy, fibroid removal etc)? *
23) Have you ever suffered with any bowel conditions such as IBS, Colitis or are you a Coeliac? *
24) Are you or have you ever been an advanced recreational or professional athlete? Runner, gymnast, trampolining or any sport that involved regular contact or blows to your abdomen? *
25) Do you have a history of low back pain or any other type of back pain? *
26) Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx)? *
27) Do you have a DAILY bowel movement? *
27a) Do you suffer from constipation or regularly strain on the toilet? Do you need to assist your own voiding? *
28) Do you or have you ever had a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma)? *
29) Are you or have you ever been overweight? *
30) Do you frequently lift heavy weights (gym, work, carer, children)? *
31) Are you incontinent overnight or wake in the night often to urinate? *
32) Are you on any medication? *
33) Do you suffer any other medical conditions? *
34) Have you had any major surgery or trauma to your body? *
35) Does your work / daily activity involve lots of sitting, walking or lifting? *
36) Have you ever been diagnosed with a Thyroid issue or taken any Thyroid medication? *
37) Do you have any intolerances/allergies? *
38) Do you take any hormone correction medication? *
39) Do you have either Type 1 or Type 2 Diabetes? *
40) Do you add sugar to your food or drink? *
41) Are you on a special diet ie., vegetarian/vegan? *
42) Are you taking any supplements currently? *
43) Are you currently or previously taking any Anti-anxiety or Anti-depressant medication? *
Do you have any of the listed issues below?
If yes, please give as much information as possible in the space provided below.
43) Very flexible or unstable joints? *
44) Early onset of Advanced Osteoarthritis? *
45) Chronic degenerative joint disease? *
46) Tearing of tendons or muscles? *
47) Weak muscle tone? *
48) Osteopenia (low bone density)? *
49) Deformities of the spine? *
50) Flat feet? *
51) Temporomandibular Joint Syndrome (spontaneous locking/unlocking of jaw bone)? *
52) Short-sightedness? *
53) Abnormal/poor/slow wound healing and/or poor scar formation? *
Please rate the following on a scale of 1 - 10: