Restore Your Core & Pelvic Floor Programme

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    Your Details

    Preliminary Information

    Health Screening Questions

    Has your doctor ever said that you have a heart condition AND that you should only do exercise recommended by your doctor?
    YesNo

    Do you feel pain in your chest when you do physical activity?
    YesNo

    In the past month, have you had chest pain when you are not doing physical activity?
    YesNo

    Do you lose your balance because of dizziness or do you ever lose consciousness?
    YesNo

    Do you have a bone or joint problem that could be made worse by a change in your physical activity?
    YesNo

    Is your doctor currently prescribing drugs for your blood pressure or heart condition?
    YesNo

    Are you diabetic?
    YesNo

    Are you having trouble with your bowel, wind or urinary urges?
    YesNo

    Do you lose urinary control when laughing, sneezing, coughing, or jumping or moving quickly?
    YesNo

    Are your bowel movements or urination painful?
    YesNo

    Do you experience a feeling of heaviness in your pelvis? Or has anyone ever suggested you may have a prolapse?
    YesNo

    Do you currently or have you ever needed to wear incontinence pads?
    YesNo

    Do you experience pain inside or at the joints of your pelvis?
    YesNo

    Are you going through or have you been through menopause?
    YesNo

    Have you ever undergone any gynaecological surgery (e.g. hysterectomy, fibroids removal)?
    YesNo

    Are you or have you ever been an elite athlete? Runner, gymnast, trampolining or any sport that involved regular contact?
    YesNo

    Do you have a history or low back pain or any other type of back pain?
    YesNo

    Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx?)
    YesNo

    Do you suffer from constipation or regularly strain on the toilet?
    YesNo

    Do you have a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?)
    YesNo

    Are you or have you been overweight?
    YesNo

    Do you frequently lift heavy weights (Gym, work, children, caring for disabled or elders?)
    YesNo

    Are you incontinent overnight?
    YesNo

    Please provide any further information related to the above issues here, if applicable

    Do you know of any other reason why you should not do physical activity?
    YesNo

    Further Deails

    What are your goals for participating in exercise? What part of your physical or mental wellbeing are you most motivated on improving right now?

    What liquids do you drink during the day and how much of each type?

    How would you describe your current diet? Include any regular cravings you have.

    How is your health in general? Do you need to tell me about any other health issues you may have? Are you on any special kind of medication?

    Confirmation

    This physical activity clearance is valid for 12 months from the date that it is completed and becomes invalid if your condition changes so that you would answer YES to any of the medical questions.

    Data Protection