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Perinatal January 2022
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Health Form
YOU & YOUR HEALTH
Health Form for Yoga/ Bodywork/ Therapies
Before we work together, I need to know more about you, your current and past health. All of this information is confidential, if you prefer to email me your information,
get in touch
.
1. Your contact information
*
Indicates required field
Email
*
Name
*
First
Last
2. Your emergency contact (friend/family member etc)
Name
*
First
Last
Phone Number
*
Email
*
3. General information about you
Date of Birth (dd/mm/yyyy)
*
Physiological gender: do you have:
*
A vulva
A penis
Both
4. Your general health
Tick/check and answer where appropriate
*
I have allergies
I suffer from migraines
How frequently do you suffer from migraines
*
Never
Weekly
Monthly
3-9 times per year
Choose Any
*
I am currently on a specific diet
I have been diagnosed to have a heart condition
I suffer/suffered from chest pains/ heart palpitations/ tightness in the chest
I often feel faint or have dizzy spells
I have high blood pressure
I have low blood pressure
I take prescribed drugs/medication regularly
I have asthma
I have epilepsy
I am diabetic
I am diabetic and insulin dependant
I have irritable bowl (IBS)
I have Crohn's disease
I have diverticulitis
I have colitis
I have an auto-immune disease
I have lower back pain
I have hip pain
I have shoulder pain
I have had surgery/surgeries
I suffer from incontinence
If yes, what are they?
*
Please let me know what prescribed drugs you take. Names and doses.
*
Please let me know what kind of auto-immune disease (eg. fibromyalgia myalgia/ rheumatoid arthritis)
*
Please let me know what surgeries you have had
*
Have you had any injuries in the past i.e, back problems/ muscle/ tendon/ ligament strain, etc? Please share details.
*
5. If you have a vulva, please answer the following questions. People with a penis, you can go directly to the next section...
Have you ever been pregnant?
*
Yes
No
Are you currently trying to conceive?
*
Yes
No
Are you currently pregnant?
*
Yes
No
Are you:
*
Menstruating regularly
Menstruating irregularly
Currently not mensruating
Going through menopause
Post-menopause
Please let me know if you have had a pregnancy loss or abortion
*
If you are trying to conceive how long have you been trying?
*
If you ARE pregnant, how many weeks?
*
If you have pain or any conditions related to pregnancy, let me know. Examples, pubic bone pain, prolapse, incontinence etc
*
Select all that apply to you
*
I have diastasis recti
I have organ prolapse
I pee when I sneeze, laugh, cough, run...
I have had a caesarean
I have had a hysterectomy
I have had an episiotomy
I get urinary infections at least once a year
I have endometriosis
I get thrush/vaginal bacterial infections
If there is anything else you would like to tell me about your pelvic health, feel free to share here.
*
6. Lifestyle questions
What is your occupation?
*
Do you take part in any regular exercise? If so, what?
*
Have you had massage/ Bodywork/ Physio/ Osteopathy/ Chiropractics before? If yes, please share a brief summary of the treatment(s)
*
What would you like to get out of working with me?
*
What, if any is the major cause of stress in your life?
*
What do you do to relieve stress?
*
Is there any reason why you may not be able to receive a treatment or yoga coaching from me? If yes, please specify.
*
7. The legal bit
By submitting this form you acknowledge that you have shared information to the best of your knowledge. You agree to take responsibility for yourself during each session with Charlotte Speller. You agree for your details to be used by Charlotte Speller for marketing and communication purposes only. Your personal information is confidential and will never be shared with any third parties without your consent!
During
yoga classes
from time to time, I may record or take photos for education or marketing purposes. If for any reason you do not consent to this, please
get in touch
. When participating in
trainings online
, the content is recorded for participants to access for a limited time after the training. The training may also be sold separately, in such cases, content will be reviewed and any content deemed personal shall be removed from the recording.
I am really looking forward to us working together soon!
Submit
