Mama Wellness Pelvic Floor Dysfunction Questionnaire Date Questionnaire Completed ______Client Name: Address:

Mobile No: Email

(Permission to send offers/updates of services?)

YES/NO

Are you a member of Age: Facebook/Whatsapp? Permission to message if required? What is your facebook name?

Children: Birthing Style(s):

Diastasis Check Performed? Results?

Pelvic Floor Dysfunction (PFD) may present via a wide variety of symptoms and in order to help us to help you understand why your Pelvic Floor isn’t working as well as it used to, you’ll need to answer the following questions as fully as possible. The Mama Wellness © 2017 answers to the following questions will give us both a clearer idea of how to move forward and get you back to great core and Pelvic Health. 1. Are you experiencing difficulty with your bowel, wind or urinary Yes No urges? If yes, please state which. ? ?

2. Do you lose urinary control when laughing, sneezing, coughing or Yes No jumping or moving quickly? ? ?

3. Are your bowel movements or urination painful? Yes No If YES, please give further details: ? ?

4. Do you experience a sensation of pressure in your vagina or rectum Yes No or noticed any protrusions from your openings? Has anyone ever ? ? said you may have a prolapse? If YES, please give further details:

5. Do you experience pain with intercourse or sexual stimulation? If Yes No YES, please give details. ? ?

6. Do you currently or have you ever needed to wear incontinence Yes No pads? If yes, how many would you wear in a day? ? ?

7. Do you experience pain in your genitals with or without sexual Yes No intercourse? If YES, please give details. ? ?

8. Do you experience pain inside or at the joints of your pelvis? If YES, Yes No please give details. ? ?

9. Are you currently pregnant? Yes No ? ?

10. Have you recently (or ever) had a baby? Do you have a separation Yes No of your abdominal muscles at the midline? ? ?

11. Are you going Yes? No? through or have been through the menopause? Mama Wellness © 2017 12. Have you ever Yes? No? undergone any gynaecological surgery (eg.,a hysterectomy, fibroids removal?)

13. Are you or have you Yes? No? ever been an elite athlete? Runner, gymnast, trampolining or any sport that involved regular contact?

14. Do you have a Yes? No? history of low back pain or any other type of back pain?

15. Have you ever Yes? No? sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx?)

16. Do you suffer from Yes? No? constipation or regularly strain on the toilet? Do you need to assist your own voiding/elimination (straining etc)?

Mama Wellness © 2017 17. Do you or have you Yes? No? ever had a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?)

18. Are you or have you Yes? No? been overweight?

19. Do you frequently lift Yes? No? heavy weights? (Gym, work, children, caring for disabled or elders?)

20. Are you incontinent Yes? No? overnight?

On a scale of 1-10, how much are you troubled by your Pelvic Floor/Continence issues? A Little 1 2 3 4 5 6 7 8 9 10 Very Concerned What is the problem – in your own words?

How long have you been aware of or concerned by a change in your continence and Pelvic Floor function? Please detail any previous attempts to improve your continence.

Mama Wellness © 2017 What liquids to you drink during the course of your day and how much of each type?

Are you on any special type of Medication?

How is your health in general? Do you need to tell me about any other health issues you have?

Mama Wellness © 2017