Postpartum Rehab Guide

Please answer all questions to help get the most out of your Postpartum Rehab Guide:

First Name *

Last Name *

Email *

Date of birth *

Delivery Date *

Type of Delivery *

Delivery Complications? (leave blank if none)

How many pregnancies?

Please specify types of births for all pregnancies if more than 1.

Health History

Have you been cleared by your physician to participate in exercise program?

Did you experience any of the following during pregnancy or delivery?

Are you currently experiencing any of the following symptoms?

Pain in your pelvic area, back, or joints

Urinary incontinence(includes any degree of leaking)

Heaviness/pressure in the pelvic floor

Bleeding that hasn’t resolved

Please explain your symptoms in detail:

Have you scheduled an evaluation with a local Pelvic Floor Physical Therapist?

Exercise History

Were you physically active during pregnancy?

Do you have previous experience with structured exercise programs?

Postpartum Goals

Are there specific activities you’d like to return to (e.g., running, yoga, lifting)?

Additional Information

Do you have access to any equipment? (Please list what you have access to)

Is there anything else you’d like me to know?

Where are you located? City/State