Core & More Private Info – Pelvic Health with Chanty

Name *

First

Last

Email *

Contact Number *

DOB *

Have you seen a Women's Health Physio before? *

If yes, what did you see them for?

What date was your last baby born? *

Please give a brief account of your birth story and include how your baby was delivered. *

If you have any other children please give their date of birth as well as a brief account of each birth story.

Are you currently involved in any form of exercise? *

If yes, please provide some detail regarding type of exercise.

Please tick if you are struggling with any of the symptoms at present *

If you feel comfortable to elaborate on the above please do as it would help me understand the current condition of your body better.

Have you undergone any surgery in the past 2 months? Please give a brief description. *

What exercise (if any) did you partake in while pregnant or before surgery *

Do you have any chronic conditions or underlying health issues that I need to be made aware of? Any other aches and pain not yet mentioned?

What are you hoping to acheive from the "Core and More" program? *