Your full name

Your date of birth

Your email address

Your home address

Your Postcode

Please outline what you are most looking to achieve as a result of working with me?

Please describe and grade your main issue out of 10 and highlight any other additional issues you would like to address/feel relevant? Please be as honest as you can.

Please provide details and dates of any pregnancies (including current) and birthing history.

Have you been diagnosed with a DRA (Diastasis Rectis Abdominus) / separation of your abdominals?

Have you ever been diagnosed with any form of prolapse? Please provide details

Do or have you suffered from asthma, chronic coughing / sneezing, constipation, loose bowels or vomiting, including anorexia or bulimia? Please provide details.

Do you experience problems with your bladder and/ or bowels, including consitpation / straining, urgency, lack of control, uncontrollable wind (including vaginally). Please provide details.

Do you ever experience a dropping sensation, heaviness or a protrusion from your vaginal or rectal orifices. Including when exercising, gardening, standing or lifting. Please provide details.

Have you ever received professional help for these problems? Please provide details and outcomes?

Please provide details of additional medical issues or hospital stays over the last 5 years?

How do you like to get exercise and how often?

Do you frequently lift heavy weight, including children and gardening?

How do you like to relax and how often?

How would you best describe your energy levels throughout the day?

How do you describe your current health and lifestyle in comparison to what you aspire to?

I have understood and answered all of the information honestly and to the best of my knowledge. I understand that I must notify Sarahjane of any changes to my circumstances and or medical history. I understand that I am entering into a voluntary restorative and graded exercise program and have a right to withdraw at any time.
I also understand that whilst every effort will be made to prevent and minimise risk of injury there is always a risk of injury through exercise and that I must notify Sarahjane of any pain or malaise immediately. I understand that Fit Fanny Adams will never share my data and only collect and use relevant information as outlined in the privacy policy.
yesno