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Please tick if you have experienced any of the following during or after pregnancy

SPD (Pelvic girdle pain)

Pelvic floor weakness

Sacroiliac pain

Chest pains

Hear disease

Diabetes

Hight blood pressure

Low blood pressure

Multiple births

Knee pain/problems

Back pain/problems

Vaginal bleeding

Dizziness/fainting

Neck pain/problems

Miscarriage

Divarification/split abs

Constipation

Pain in the pelvic floor

Posterior pelvic floor weakness

Is there anything in your medical history I would need to know?

Yes

No

Are you taking any medication? If YES please give details

Yes

No

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