First name

Last name

Your occupation

If you are early Post Natal, have you had your 6-8 week check? yesnon/a

Your date of birth

Your email address

Phone number

Please answer yes or no to the following questions. Answer YES even if you only partially agree with the statement. Then use the space below the questions to give further details.

1) Are you experiencing difficulty with your bowel, wind or urinary urges? yesno

2) Do you lose any urinary control when laughing, sneezing, coughing, jumping, walking, moving from sitting to standing or moving quickly? Or leak without warning? yesno

3) Are your bowel movements or urination painful? yesno

4) Is there any blood present in either your stools or urine? yesno

5) Do you experience any urinary hesitancy ie starting/stopping of your urine stream or incomplete emptying? yesno

6) Do you often think you need to go to the toilet to urinate - 'Just in case'? yesno

7) Do you lack the ability to hang on if you have to urinate or have a bowel movement? yesno

8) Do you experience a sensation of pressure in your vagina or back passage, or noticed any protrusions from your vagina or back passage? Has anyone ever said you may have a prolapse? yesno

9) Do you currently have or have you ever needed to wear incontinence pads? yesno

10) Do you experience pain in your genitals and / or pelvis with or without sexual intercourse? yesno

11) Do you experience pain inside or at the joints of your pelvis? yesno

12) Are you currently pregnant? yesno

13) Have you recently (or ever) had a baby? If Yes, please state how you gave birth in the section below (vaginal/C-Section/Forceps/Labour Length etc) yesno

14) If Post Natal, are you still breastfeeding? yesno

15) Do you have separation of your abdominal muscles at the midline (Diastasis)? yesno

16) Do you have any problems wearing or inserting tampons? yesno

17) Are you going through or have you been through the menopause? yesno

18) Have you ever undergone any gynaecological surgery (hysterectomy, fibroid removal etc)? yesno

19) Have you ever suffered with any bowel conditions such as IBS, Colitis or are you a Coeliac? yesno

20) Are you or have you ever been an advanced recreational or professional athlete? Runner, gymnast, trampolining or any sport that involved regular contact or blows to your abdomen? yesno

21) Do you have a history of low back pain or any other type of back pain? yesno

22) Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx)? yesno

23) Do you have a DAILY bowel movement? yesno

23a) Do you suffer from constipation or regularly strain on the toilet? Do you need to assist your own bowel movement? yesno

24) Do you or have you ever had a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma)? yesno

25) Do you frequently lift heavy weights (gym, work, carer, children)? yesno

26) Are you incontinent overnight or wake up in the night often to urinate? yesno

27) Are you on any medication? yesno

28) Do you suffer with any other medical conditions? yesno

29) Have you had any major surgery or trauma to your body? yesno

30) Does your work / daily activity involve lots of sitting, walking or lifting? yesno

31) Do you have any intolerances/allergies? yesno

32) Do you take any hormone correction medication? yesno

33) Do you have either Type 1 or Type 2 Diabetes? yesno

34) Do you add sugar to your food or drink? yesno

35) Are you on a special diet ie, vegetarian/vegan? yesno

36) Are you taking any supplements currently? yesno

37) Are you currently or previously taking any anti-anxiety or anti-depressant medication? yesno

If you answered Yes to ANY of the above questions, please give further detail in the space below. Please use this space if you have ever given birth to give details of the delivery (vaginal, C-Section, Episiotomy etc).

What liquids do you drink during the day and how much of each type? How much alcohol do you drink per day?

On a scale of 1-10, how much are you troubled by your Core/Pelvic Floor issues? 1 = "a little" 10 = "very concerned" 12345678910

So on a scale of 1-10, how would you rate your day-to-day life stress levels? 1 = "not stressed" 10 = "very stressed" 12345678910

In your own words what is/are the problems? What are your reasons for seeking help via this programme? What are your goals? Please detail any previous attempts to improve your situation.