Pelvic Health Questionnaire

The following questions are designed to assess your pelvic health. This questionnaire is of particular importance when returning to exercise postpartum. Please answer the following questions honestly, the answers provided will be taken into consideration whilst programming exercise. If at any point during exercise sessions you feel any discomfort in your pelvic floor or experience any stress incontinence, it is vital that you communicate this.

Name

First Name

Last Name

Do you suffer from stress incontinence? (do you leak any urine when you cough, sneeze or during exercise?)

Do you have a pelvic organ prolapse? (either a uterine, bladder or bowel prolapse, or a combination of these)

If you answered ' yes' above please give further details regarding the type and and stage of your prolapse (if known):

Have you seen a pelvic health physiotherapist since giving birth?

If you answered 'yes' above and are happy for me to share information with your physiotherapist in order to effectively prescribe exercise, please confirm and provide their details here:

Have you had a vaginal delivery?

Did you have an instrumental delivery? (was your baby delivered by ventouse/forceps?)

Did you have a prolonged second stage of labour?

Do you experience any of the following symptoms, either whilst exercising or during activities of daily living?

Leaking of bladder or bowels

Pelvic floor heaviness/dragging

Feeling of (or seeing) a bulge in your pelvic floor

Pelvic pain or lower back pain

Gap in your tummy, 'doming' or pendular abdomen

Please use the box below to provide any additional information about your birth/c section or pelvic health in general that you feel may be useful for the prescription of exercise: