Name * First Name Last Name SETTING BOUNDARIES Throughout our coaching partnership, there may be things that come up that you are or are not comfortable talking about. Topics such as your pelvic floor health, nutrition, sleep, and stress, may all have an impact on your training and your results to varying degrees. Please indicate which topics you are comfortable talking about with me by checking the relevant boxes (or checking the first box if you are comfortable talking about all of them). If you are not comfortable talking about a certain issue with me, leave the box(es) blank. You may change your decision at any time, just let me know. I am comfortable talking about: * all of the topics listed below Birth experience birth injuries or complications c-section recovery postnatal pleeding pregnancy experience menstrual cycle pelvic floor health diastasis recti incontinence pelvic organ prolapse breastfeeding breast tenderness or pain sleep stress emotional issues and mental health body image past pregnancies weight There may also be instances where it can be helpful for me to manually cue or manually assess you, which requires physical touch. Please indicate which body parts you are comfortable having me manually cue or assess by checking the relevant boxes. I will also obtain your verbal consent before manually cueing or assessing you during a training session. I am comfortable with my coach manually cueing and assessing: all the body parts below feet legs hands arms head glutes abdomen upper back lower back neck YOUR BIRTH EXPERIENCE Date of child's birth MM DD YYYY Birth type * vaginal assisted (i.e. forceps, vacuum) c-section Are you currently experiencing any postpartum bleeding? If so, have you consulted with your doctor about it? Are you currently breastfeeding? * yes no Have you had your 6 week check up with your PCP? * yes no Did your PCP clear you for exercise? If yes, did they recommend any limitations to exercise, and what are they? * What's your current activity level? * YOUR PAST BIRTH EXPERIENCE(S) Please fill out this section if you've experienced birth in the past. If you haven't, skip down to "Your Pregnancy and Postnatal Experience" Date(s) of birth(s): Birth type: vaginal assisted c-section Is there anything else you want me to know about your past birth experience(s) YOUR PREGNANCY AND POST NATAL EXPERIENCE How did you feel during this pregnancy? Did you experience any symptoms or issues that impacted your ability to exercise? * Have you met with any of the following healthcare professionals in the last 12 months? physiotherapists acupuncturists chiropractors Please describe the reason(s) for your visit(s) Have you experienced any of the following since your birth? Please let me know of any uncomfortabilities that may affect you in the gym. If so, please check the boxes and provide relevant details in the space provided. Musculoskeletal central pubic area pain coccyx (tailbone) damage or pain lower back pain pins and needles shooting or radiating pain in back, glutes, or legs abdominal bulging or doming neck pain knee pain other join pain other Pelvic Health heaviness, dragging, or bulging in the pelvic area pelvic area pain around c-section incision/scar diagnosis of pelvic organ prolapse leaking urine while coughing, sneezing, exercising, or exerting yourself strong and sudden urge to urinate leaking of urine at rest difficulty or discomfort w/passing urine uncontrollable gas leaking of feces straining during bowel movements pain in the perineum during sexual intercourse (or any other time) unexplained bleeding during or after exercise Other hemorrhoids or anal fissures varicose veins constipation gestational diabetes preeclampsia high blood pressure low blood pressure other Please provide details if you checked any of the above Is there anything else you'd like me to know about this or past pregnancies or births? YOUR HEALTH DETAILS Have you ever had surgery or any major medical event you want me to know about? YOUR TRAINING In general, what are your goals for training right now? * Check all that apply rehab & recover from pregnancy and 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 improve or manage my mental health feel more in control have fun improve overall health change body composition other Out of the goals you checked, list your top 3 in order of importance What was your exercise routine like before becoming pregnant? What was your exercise routine like during pregnancy? Is there anything you want to change about how you exercise moving forward compared to how you trained pre-pregnancy and during pregnancy? Are there any activities you want to resume/start? YOUR LIFESTYLE The purpose of the following questions is to help me, as your coach, get a better understanding of your lifestyle. Sleep, nutrition, hydration, and stress all affect your training and recovery. When I have a better understanding of these factors, I can modify your workouts according to ensure you can recover. It also helps us work together to make sure your program leave you feeling strong and energized. Stress and Recovery How much sleep do you get in a 24-hour period? Rate your general stress level on a scale of 1 to 10 (little to extreme) Rate your general energy level on a scale of 1 to 10 (exhausted to fully energized) Environment Who do you live with? (e.g. spouse/partner, parents, roommates, pets, children) What, if any, major obstacles are you encountering at home or with loved ones when it comes to your efforts to train, eat, and recover? YOUR COACHING Why did you enroll in postnatal coaching? What do you hope to get out of our coaching experience? What do you expect from me as your coach? Is there anything else you want to share that you haven't been asked yet? PHEW! You're finished! Thank you so much for taking the time to fill this out:) Thank you! Postpartum Program Client Questionnaire
