Email Address

Do you go by any other preferred names?

What are your pronouns?

Is there anything you would like to share, or have me know, about your gender or gender identity?

Is there anything you would like to share, or have me know, about your cultural values?

If YES, please describe your workouts...

What are 3 goals you'd like to work toward over the next few weeks / months?

Why are these goals important to you now?

How long have you been thinking of taking action toward these goals, and what has prevented you from taking action sooner?

How many days per week are you able to participate in physical activity for exercise?

How long are you able to participate in physical activity each day?

Any other injuries?

Any other medical conditions?

Have you had surgery? Please explain in detail.

Are you taking medication? If YES, what kind and for what condition.

Are you pregnant? If YES, how far along are you?

Do you have any children? Please provide their names and birthdates

Please describe your pregnancies and deliveries (if applicable)?

(Vaginal, planned or unplanned C-section?, medical interventions such as vacuum, forceps, episotomy?)

Have you experienced any pregnancy or infant loss you would like to share about, or you think is important for me to know?

Do you experience any pelvic floor dysfunction symptoms?

(ie. heaviness in your pelvic floor, incontinence, urge to pee, leakage, bulging, etc.) If YES, please describe...

Have you ever been to a pelvic floor physiotherapist?

If YES, please provide his / her name and your diagnosis.

Do you smoke? If YES, how many per day.

Alcohol Consumption

What have you had to eat and drink over the last 24 hours?

Do you take supplements? If YES, please explain.

What is your relationship with food like? Is there anything about your relationship to food in the past that you feel is important for me to know?

What is your relationship with your body and body image like? Is there anything about your relationship with your body and your body image in the past that is important for me to know?

What time do you go to bed at night and what time do you wake in the morning?

If you are currently working outside of the home, what is your occupation and working hours? Are you on maternity leave?

How is your support system? Partner? Family? Friends? Doula? Mental Health Therapist?

Have you, or are you experiencing postpartum depression, anxiety or post-traumatic stress disorder symptoms?

How are you managing? Mentally and emotionally?

What do you do to nourish yourself?

Is there any additional information you'd like to share?

Online Personal Training : Health History

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