Health information form

Name *

First Name

Last Name

If you answered yes to the above, please let me know if you are experiencing/have experienced any of the following birth/pregnancy/postpartum related issues:

Pelvic girdle pain

High blood pressure

Back/joint pain

Exhaustion

Sciatica

Anaemia

Stiff neck / shoulders

Anxiety

Depression

Diastasis recti

Other (please specify in box below)

Please specify if you have experienced/are currently experiencing any of the following physical challenges:

physical injury (please specify below)

back or joint pain

chronic illness (please specify below)

anxiety

depression

hernia

high blood pressure

circulation problems

asthma

epilepsy

dizziness

arthritis

cancer

diabetes

heart condition

stroke

chest pain