Pelvic Floor Relaxation Training Intake Form
Please complete this intake form to help us understand your needs and provide safe, effective pelvic floor relaxation training.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you previously participated in pelvic floor training?
*
Yes
No
What are your primary reasons for seeking pelvic floor relaxation training? (Select all that apply)
*
Urinary incontinence
Pelvic pain
Postpartum recovery
Stress management
Other
Please list any current symptoms or concerns related to your pelvic health.
*
Have you had any relevant medical conditions or surgeries (e.g., pelvic surgery, childbirth, chronic pain)?
*
How would you rate your current stress level?
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
What are your personal goals for pelvic floor relaxation training?
Are you currently receiving any other treatments or therapies for pelvic health? If yes, please describe.
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature (Please sign to confirm your consent and understanding)
*
Submit Intake Form
Submit Intake Form
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