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Mamasterk Intake
Postpartum Questionnaire
This questionnaire is designed to help me learn what I need to know to help you stay safe and healthy while reaching your postpartum goals. Please take your time and fill out this questionnaire as honestly as possible.
Contact information
Name
(Required)
Pronouns
(Required)
She/her/hers
He/him/his
They/them/their
Other (if you're comfortable, specify in the last question of the form!)
Date of birth
(Required)
DD slash MM slash YYYY
Phone number
(Required)
Email
(Required)
Instagram handle
Occupation
Emergency contact name
(Required)
Emergency phone number
(Required)
Medical history & Birth Experience
When did you give birth?
(Required)
What kind of birth experience did you have?
Vaginal
Assisten (forceps, vacuum)
C-Section
Did you experience any birth complications?
(Required)
In terms of your pelvic health, are you currently experiencing...
Heaviness, dragging, or bulging in the pelvic area
Diagnosis of pelvic organ prolapse
Pain around C-Section or scar
Leaking urine while coughing, sneezing, exercising, or exerting yourself
Leaking of urine at rest
Straining during bowel movements
Unexplained bleeding during orafter exercise
Other
Use this space for details on any boxes checked above. Please include when symptoms started/diagnosis happened, any treatment(s), and current status.
Are you currently breastfeeding?
(Required)
Have you seen a pelvic floor physical therapist since delivery?
(Required)
Has your doctor or physiotherapist recommended any limitations for your exercise postpartum? If so, what are they?
(Required)
How did you feel during this pregnancy? Did you experience any symptoms or issues that impacted your ability to train?
(Required)
Is there anything else you’d like me to know about this pregnancy or delivery?
(Required)
Are you currently taking any medications or supplements? If you’re comfortable, please specify type, dosage, and reason.
(Required)
Do you have a (family) history of heart trouble, high blood pressure, asthma or diabetes?
(Required)
Have you been hospitalized for any reason? If so, please explain.
(Required)
Do you have any other medical conditions that have not been mentioned so far that are relevant to your fitness journey?
(Required)
Health & Fitness
How is your mental wellbeing postpartum?
(Required)
How would you describe your daily activity level (intense/moderate/sedentary)? Why?
(Required)
What degree of stress are you under on a scale of 1-10 (10 is highly stressed)? What makes you say so?
(Required)
Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.
(Required)
Do you currently take part in physical exercise? If so, what and how often?
(Required)
If your participation in exercise is lower than you would like it to be, why is that?
(Required)
What was your exercise routine like while you were pregnant? How many times per week and what types of exercise?
(Required)
What was your exercise routine like before becoming pregnant? How many times per week and what types of exercise?
(Required)
Developing your program
What are your goals for training right now?
Rehab & recover from pregnancy & birth
Rebuild or improve strength
Rebuild or improve aerobic condition
Reduce or prevent aches and pains
Improve core & pelvic floor function
Improve or manage my mental health
Change body composition
Have fun
What do you feel are the obstacles that could challenge your journey to your training goals?
(Required)
What are your favourite fitness activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)
(Required)
What are your LEAST favourite fitness activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)
(Required)
Realistically, how often would you like to exercise together?
(Required)
What are the best days/times during the week for you to commit to your program?
(Required)
Our coaching relationship
What drove you to seek out coaching postpartum?
(Required)
Describe your ideal coaching relationship? What is my role in your fitness journey?
(Required)
How can I help you reach the goals you listed?
(Required)
Anything else you’d like me to know about you? Personality? Needs? Core values? Anything that would help me get a better sense of YOU is totally encouraged here...go wild!
(Required)
Acknowledgment, participant release & cancelation policy
Consent
By checking the boxes below, I acknowledge and agree to the terms as stated below.
Consent
I have read, understood to my full satisfaction, and completed this questionnaire.
Consent
I understand and agree that it is my responsibility to inform Fit With Lou of any condition or changes in my health that might affect my ability to complete the program safely.
Consent
I agree that Fit With Lou shall not be liable or responsible for any injuries to me resulting from my participation and I expressly release and discharge Fit With Lou from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.
Consent
I understand that Fit With Lou operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. Where less than 24 hours notice is given, I understand that rescheduling will not be possible. My coach will utilize that time to further develop my program.
Consent
I agree to an initial 3-month commitment to coaching with Fit With Lou. After three months, I understand my contract will automatically renew on a month-to-month basis. I agree to give notice of 1 calendar month via email to hello@withlou.com in order to cancel the contract. I acknowledge that there are no refunds available on this investment.
Phone
This field is for validation purposes and should be left unchanged.