Skip to content
Home
Meet the Team
Pilates
Physiotherapy
Aches and Pains of Pregnancy
Post Natal Checks
Gynae Surgery Support
Urinary Incontinence
Bowel Problems
Pelvic Organ Prolapse
Paediatric continence (bed wetting, constipation)
Acupuncture and Dry Needling
Shop
Education
Price List
Contact Us
Menu
Home
Meet the Team
Pilates
Physiotherapy
Aches and Pains of Pregnancy
Post Natal Checks
Gynae Surgery Support
Urinary Incontinence
Bowel Problems
Pelvic Organ Prolapse
Paediatric continence (bed wetting, constipation)
Acupuncture and Dry Needling
Shop
Education
Price List
Contact Us
Book an Appointment
Or call 016284674
One-To-One Pilates Appointment Request
Step
1
of
4
25%
Name
(Required)
Email
(Required)
I understand that I am undertaking exercise at my own risk and must listen to my own body
(Required)
Yes.
Occupation
(Required)
Preferred Day
Tuesday
Friday
Phone
(Required)
What are your hobbies or interests?
(Required)
Is pain stopping you from doing any of these comfortably right now?
(Required)
How would you describe your current level of fitness?
Sedentry & Unfit
2
3
4
5
6
7
8
9
Olympic Athlete
Are you on any medication? If yes, please give names
Do you suffer with any of the following :
Heart/vascular condition including blood pressure issues
Diabetes
Epilepsy
Asthma
Arthritis
Osteoporosis
Back pain or other joint injury
None of the above
Other Ailments
Male / Female
(Required)
Male
Female
If you are female please complete the rest of this page, if not please continue to the last page.
Are you pregnant? If yes how many weeks and have you been experiencing any complications
How many children do you have?
0
1
2
3
4 or more
If you have recently had a baby, please let me know how many weeks/months/years old this youngest baby is
0 - 3 months
3 - 6 months
6 - 12 months
More than one year
Not applicable
Please let me know about the types of deliveries or any complications you may have had
Vaginal delivery
Forceps or ventouse delivery
Emergency caesarian section
Planned caesarian section
Baby over 4kg (9lbs)
Post partum complications
Wound infection/wound breakdown
Pelvic girdle pain
Perimenopause symptoms
Muscular aches and pains
Difficulty sleeping
Anxiety
Low mood
Weight gain despite all efforts
Pelvic floor symptoms - see specific Question relating to this for details
I ask these questions as Pilates can be helpful for some of these problems, but I also want to draw your attention to how you might be feeling and if you might need to seek help from your GP or menopause specialist rather than suffer on in silence...
Have you had any pelvic floor/gynae surgery? If so what type of surgery and when.
Are you experiencing any of the following pelvic floor symptoms?
Urinary leakage with exercise or cough/sneeze
Strong urgency to pass urine
Leakage of urine on the way to the toilet
Feelings of heaviness/pressure in the vagina or back passage
Painful intercourse
Difficulty or pain when passing a bowel motion
Strong urgency or leakage of solid or Liquid stool
None of the above
Please know this this information is taken in confidence to help me devise the best class to meet your needs. Pilates has been shown to strengthen the pelvic floor but where there are actual symptoms, targeted physiotherapy is more effective in resolving issues than pilates alone. Please feel free to speak with me in confidence.
Thank you for taking the time to complete this. Please use the space below to tell me anything else you feel may be relevant to your return to pilates.
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
CAPTCHA
Home
Meet the Team
Pilates
Physiotherapy
Shop
Education
Price List
Contact Us
Home
Meet the Team
Pilates
Physiotherapy
Shop
Education
Price List
Contact Us
Facebook-f
Twitter
Instagram