Movement Intake FormThis form is to help me get to know about your movement story, your relationship with your body, your birth(s) and what motivates you. Name * First Name Last Name Date Of Birth MM DD YYYY Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### How did you hear about me> Referral Google Friend Instagram Facebook Marketing Flyer Are there any limitations, injuries or medical accommodations you need, or would like to share with me about? If you have kids, tell me briefly about their birth(s) (Vaginal, C-Section) What was the length of your labour(s), if applicable and known? What was the length of your pushing stage(s), if applicable and known? Did you have any medical intervention in your birth(s), including forceps, vacuum, epidural, episiotomy or anesthesia? Did you experience any tearing internally or externally? Do you know the degree? Was stitching done? Do you have a menstrual cycle? Is it Regular? Do you notice any physical, mental or emotional changes in the different phases of your cycle? Are you currently breastfeeding? How much sleep do you usually get in a 24 hour period? What does your support system look like? How much parenting or child rearing do you do, if applicable? Have you been assessed by a women's health physio? If yes, was it helpful? Have you been told you have Pelvic Organ Prolapse, Diastasis Recti, hernia or any other pelvic or abdominal symptoms? Do you or have you experienced tailbone pain? Have you or do you currently experience any of the following? Leaking when laughing, coughing, sneezing or exercising Difficulty emptying bladder Having to push to empty bladder Urgency or needing to wee more than usual Inconsistent stream while weeing Have you or do you currently experience any of the following related to your bowel movements? Constipation (less than one poo a day) Straining to have a bowel movement Difficulty fully emptying bowels Hemorrhoids or blood in bowel movements Do you ever feel any of the following? Heaviness, dragging or bulging sensation in your pelvic floor, vagina, vulva or perineum A sensation of something pushing or falling out of your vagina Pain or discomfort during sex/penetration Pain or discomfort in the front of the pelvis Pain or discomfort inserting a tampon or cup Pain or discomfort in the back of the pelvis Low back pain Pain in the buttocks Other Do you have any pain or discomfort anywhere else in your body? Have you had any surgeries? Would you like to share with me about them? Are you currently physically active? If yes, what do you like to do to exercise? Do you have a particular workout routine or schedule? Do you have any physical goals? Do you have any lifestyle goals? Less stress, more energy, community, happiness, improved sleep etc. What do you do to nourish yourself? What does self care look like to you? Do you do professional or career work? How are you managing mentally and emotionally? What is your relationship to your body, and body image like? Is there anything about your relationship to your body that is important for me to know? Have you or are you currently experiencing depression, anxiety, post-traumatic disorder symptoms or any other mental health concerns you'd like to share with me? Have you accessed or utilised any treatments for your mental health support? Have you ever worked with a personal trainer before? If yes what was your experience? Realistically, how many days a week would you like to train/workout? (this includes any workouts you would like to do at home). What are you looking for in me as a trainer? Is there anything else you'd like to share with me? Thank you so much, I look forward to getting to know you! Zoe
