Please list any muscle aches or pains you have:
PAST MEDICAL HISTORY
Have you had any Gynecological or urological surgery?
Date(s) and type of surgery/reason?
Have symptoms fully resolved?
Do you have any abdominal scars?
Describe location of the scars:
Please state any fractures with dates:
Please list up to three activities, movements or positions that bring on your pain/problem? (e.g. Lifting, running, sitting)
Have you any CONCERNS now or for after your baby is born? (Please check all that apply)
Gap in tummy muscles (diastasis)Sexual ConcernsAnxietyMood ImbalanceBladder ProblemsMusculoskeletal ProblemsPelvic Girdle PainSleep DeprevationBowel IssuesProlapsePain on IntercourseBack Pain
Any Other Concerns:
URINARY SYMPTOMS (Please check all that apply)
Urinary frequency (going often)Pain on passing urinereducedReduced flow of urineUrinary Urgency (rushing to go)LeakingUTIs (Infections)Problems empyting your bladder completelyStress incontinence (leaking on cough, exercise etc)
BOWEL SYMPTOMS (Please check all that apply)
UrgencyConstipationNot feeling that you empty your bowels completelyLeakingPressure on the rectumAssistance to empty your bowelsPain on opening bowels
PELVIC FLOOR SYMPTOMS (Please check all that apply)
Do you experience discomfort in your vagina or rectum? (back passage)?
Have you been diagnosed with a prolapse now or in the past?
Do you have pain during intercourse?
Previous Obstetric Hx. If Relevant
How many children do you have?
Method of Delivery:
Weight of baby at birth:
Concerns post delivery:
What are your three top concerns/goals to achieve from the Mummy MOT® Team?
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS
Connective tissue disorders (eg Lupus)Hypermobility syndromes (eg Ehlers Danlos )Thyroid DiseaseHeart ProblemsRespiratory ProblemsDiabetes Type 1 or 2CancerBowel Conditions (IBS/colitis)EndometriosisCoccyx InjuriesBack Pain
Any other conditions you are being treated for:
MEDICATIONS INCLUDING SUPPLEMENTS
Have you ever been on a course of steroid treatment?
Have you ever been on Warfarin or blood thinning medications (eg for blood clots)?
Any other medications/supplements:
Details of medications:
CURRENT PELVIC FLOOR EXERCISE
How often are you currently practising pelvic floor exercises?
Are you confident you are doing them correctly?
ANY OTHER COMMENTS
The Data Protection Officer with responsibility for monitoring this privacy notice is Katie Ballard.
We may collect the following information:
• Contact information including email address
• Demographic information, such as postcode, preferences and interests
• Personal information including detailed medical information for the purposes of providing treatment.
• Other information relevant to client enquiries
Collecting this data helps us to ensure that we can provide a safe and beneficial service to our clients.
Specifically, we may use data:
• To ensure that we have the information required to provide safe and appropriate physiotherapy or Pilates service.
• To handover to members of the team who may be involved in the care pathway.
• To ensure that we meet the statutory requirements for the HCPC governing physiotherapists.
• To contact you via email, telephone or email regarding your inquiry.
• To send you details of offers, updates on services and free wellness and self-help guidance.
– We will never lease, distribute or sell your personal information to third parties unless we have your permission or the law requires us to do so.
– Information is not stored for the purpose of sending automated emails regarding our services.
Through agreeing to this privacy notice you are consenting to KTB Rehabilitation processing your personal data for the purposes outlined. You can withdraw consent at any time or if you would like to discuss anything in this privacy notice, please contact Katie Ballard at KTB Rehabilitation Westgate House Spital Street Dartford DA1 2EH or by email Katie@www.pilatesandtherapy.co.uk
If you have a concern about the way we are collecting or using your personal data, you should raise your concern with us in the first instance or directly to the Information Commissioner’s Office at https://ico.org.uk/concerns/
Access to your information
Your rights as a data subject
At any point whilst we are in possession of, or processing your personal data, all data subjects have the following rights:
• Right of access – you have the right to request a copy of the information that we hold about you.
• Right of rectification – you have a right to correct data that we hold about you that is inaccurate or incomplete.
• Right to be forgotten – in certain circumstances you can ask for the data we hold about you to be erased from our records.
• Right to restriction of processing – where certain conditions apply you have a right to restrict the processing.
• Right of portability – you have the right to have the data we hold about you transferred to another organisation.
• Right to object – you have the right to object to certain types of processing such as direct marketing.
• Right to object to automated processing, including profiling – you also have the right not to be subject to the legal effects of automated processing or profiling.
To access what personal data is held about you, identification will be required. One piece of photographic ID and one item of supporting documentation such as a utility bill or bank letter will be required. Requests should be made to Katie Ballard.
To prevent unauthorised disclosure or access to your information we have implemented strong physical and electronic security safeguards.
Our website is scanned on a regular basis for security holes and known vulnerabilities in order to make your visit to our site as safe as possible.
Your personal information is contained behind secured networks and is only accessible by a limited number of persons who have special access rights to such systems, and are required to keep the information confidential. All our data processors have been vetted to comply with GDPR safety regulations.
Only staff engaged in providing your treatment will have access to your patient records, although our administration team will have access to your contact details so that they can make appointments and manage your account.
KTB Rehabilitation will not disclose your Personal Information unless compelled to, in order to meet legal obligations, regulations or valid governmental requests.
Our website may contain links to other websites. Please note that we have no control of websites outside the KTB Kids domain. If you provide information to a website to which we link, we are not responsible for its protection and privacy.
Always be wary when submitting data to websites. Read the site’s privacy policies fully.
KTB Rehabilitation will process personal data during the duration of any treatment and will continue to store only the personal data needed for eight years after the contract has expired to meet any legal obligations. After eight years, all personal data may be deleted, unless basic information needs to be retained by us to meet our future obligations to you, such as erasure details. Records concerning minors who have received treatment will be retained until the child has reached the age of 25.
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