Name
*
First Name
Last Name
Email
*
How many weeks (or months) postpartum are you?
Which pregnancy and birth is this for you?
First
Second
Third
Fourth or more
Describe how your most recent pregnancy experience felt physically? Did you experience pains, injuries, or complications?
What type of birth did you have (vaginal or C-section)?
Did you experience vaginal tearing or other complications? If so, please describe.
Overall, how would you describe your birth experience in terms of difficulty? (i.e. "relatively" easy or difficult) How did it compare with your expectations?
Any complications or physical limitations?
Are you currently cleared by your doctor for physical activity?
Have you done any other recovery work (i.e. physical therapy, pelvic floor therapy, etc)? If so, please describe.
Do you experience accidental urine leakage during sudden movements (coughing, laughing, sneezing) or during exercise?
Did your medical provider check you for pelvic organ prolapse? If not, do you ever have a heavy "bowling ball" feeling between your legs?
Did your medical provider check you for diastasis recti? If so, did your doctor confirm you have it? If so, what degree?
Did your medical provider give you any restrictions or guidance at your postpartum check-up?
Are you currently nursing or pumping?
Do you have any other (non-pregnancy related) pains, injuries, or medical conditions? If so, please list.
Have you ever had a major surgery or injury? If so, does it still impact you today?
Do you currently take any medications (OTC or prescription)? If so, for what conditions?
Please describe your PRE-pregnancy exercise routine (days/week, intensity, exercise type)
Please describe your PREGNANCY exercise routine (days/week, intensity, exercise type).
If relevant, describe your POSTPARTUM exercise routine (days/week, intensity, exercise type).
What would you love to achieve through 1:1 coaching?
Do you have a timeframe in mind for when you'd like to start seeing progress toward your goals?
How many days/week feels realistic for you to exercise right now?
What types of exercise or physical activity do you enjoy most?
Is there anything else you'd like me to know about your journey, goals, or challenges so I can best support you?
