Postpartum Self Discovery Consultation Form

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Please fill this form if you would like some help regarding your postpartum recovery journey

Today's Date *

YYYY

Full Name (First, Last) *

Full address including postal / zip code *

Age *

Date Of Birth *

YYYY

Email Address *

Instagram Handle

How many pregnancies have you had? *

have you experienced any pregnancy loss or infant loss that you would like to tell me about or that you feel it would be important for me to know? *

What are the birth dates of your children? (Month and year) *

Please go into detail regarding the births you experienced (vaginal and/or cesarean) , planned, unplanned, length of labour's and length of pushing phase if relevant. *

Did you experience any medical interventions in your birth including forceps, vacuum, episiotomy, spinal tap, epidural or anesthesia? *

Did you experience any tearing internally or externally? Did you receive stitches? *

What is your current sleep pattern looking like? (hours and sleep quality) *

Are you experiencing or have you experienced any bladder control issues? (Sudden urge, unable to hold, leaking randomly, leaking during exercise, anything else?) *

How many bowel movements do you have per day? *

Have you ever experienced the feeling of heaviness , dragging, like something's falling out or bulging in your pelvic floor, vagina or perineum? *

Are you experiencing any pain throughout your lower back, hips or pelvis area? *

Have you ever seen a pelvic health physio? *

Do you have any other health issues or bone or joint problems that may affect your ability to exercise? *

Have you experienced any mental health issues surrounding your pregnancy? (Pre-pregnancy? During pregnancy? Postpartum? Anxiety? Depression? Psychosis? PTSD?) *

What is your short term health and fitness goal? What will change on your life should you reach this goal? *

What is your long term health and fitness goal? Why? What would change in your life should you achieve this/ these goal/s? *

How much water do you drink per day? *

How many meals do you eat per day? *

How much caffeine do you consume per day ? *

Have you ever experienced any eating disorders? If so please feel free to share in detail below, or, briefly mention your situation and length of time. *

Have you ever worked with a coach online before? If so, how was your experience? *

Is there anything else you would like to share with me in order for me to know exactly how to help you best? *

Would you like to have a complimentary 30 minute discovery call with me to discuss your goals? *

Best method of contact? Phone (Canada only), Skype, WhatsApp, Facebook Messenger *

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