Online PT Registration – Pre Questionnaire

Your Name *

Your Email *

Address

Phone

Do you want to incorporate your PT sessions as part of the next challenge?

YesNo

How many Online PT sessions would you like per week? Would you like 30 or 45min sessions?

What times & weekdays are you available for your session/s each week? Please note weekends are unavailable. School hours preferable. Some evening slots available.Please give multiple options where you are available.

What are your top 3 goals?

Why are these goals important to you?

What has stopped you from achieving your goals in the past?

Do you have any injuries or medical conditions?

On a scale of 1-10 what are your energy levels like?1 = low, 10 = high

On a scale of 1-10 how confident are you?1 = low, 10 = high

Training history - are you currently exercising? What sort of exercise are you doing? How long have been doing this for?Please be specific

If you have children - what is their age?This is relevant to how far along you are postpartum

For each child, did you have a vaginal birth or c-section?

Do you experience any pelvic floor weakness?

Do you experience any doming or have abdominal separation or hernia (in your abdominal area) that you know of?Doming happens when the belly protrudes out in a dome like shape

Have you been to see a women's health/pelvic floor physio? If so please explain the outcome

Please do not fill in this field.

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