Your Details

MUSCULOSKELETAL PROBLEMS

Please list any muscle aches or pains you have:

PAST MEDICAL HISTORY

Have you had any Gynecological or urological surgery?

YesNo

Date(s) and type of surgery/reason?

Have symptoms fully resolved?

YesNo

Do you have any abdominal scars?

YesNo

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)?

YesNo

Have you been diagnosed with a prolapse now or in the past?

YesNo

Do you have pain during intercourse?

YesNo

Previous Obstetric Hx. If Relevant

Children

How many children do you have?

123456

Child 1

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 1

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 2

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 1

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 2

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 3

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 1

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 2

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 3

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 4

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 1

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 2

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 3

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 4

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 5

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 1

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 2

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 3

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 4

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 5

D.O.B:

Method of Delivery:

Complications?

Weight of baby at birth:

Concerns post delivery:

Child 6

D.O.B:

Method of Delivery:

Complications?

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?

YesNo

Have you ever been on Warfarin or blood thinning medications (eg for blood clots)?

YesNo

Any other medications/supplements:

YesNo

Details of medications:

CURRENT PELVIC FLOOR EXERCISE

How often are you currently practising pelvic floor exercises?

YesNo

Are you confident you are doing them correctly?

YesNo

ANY OTHER COMMENTS