Pear Projects Tribe Welcome Form
Pre-screening form for PPT (Pear Projects Tribe) an online workout hub!
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Have you attended sessions with me before?
If yes; Please state what course/class you attended.
Have you had any children?
No (if no please proceed to the tick boxes)
Date of your last childs delivery:
How many weeks/months post natal are you today?
Type of delivery (assisted, vaginal, C-section):
Are you breastfeeding?
Date of 6/8 week check up and outcome?
Have you been checked for a diastasis recti (gap of the tummy muscles?).
How is your post natal healing going? Have you experience any prolonged post natal bleeding? How is your C-section, tears, episiotomy?
Please provide some details of your pregnancy and post natal period including any complications, illnesses, reasons to visit your doctor or an other health practitioner, including massage, physiotherapy etc.
Have you had any other children or pregnancies?
Have you recently had the coil fitted?
Tick All That Apply
Symphysis Pubis Dysfunction (pain in the centre of pubic area)
Sacrum pain (pain in very low/mid back or top of buttocks)
Bleeding during or after exercise or any unexplained bleeding
Carpal Tunnel Syndrome (Wrist, finger, hand forearm-pain/numbness or tingling)
High/low blood pressure or episodes of faintness, dizziness or breathlessness
Upper back/neck/shoulder pain
Coccyx damage or pain
Separation of your abdominal muscles (diastasis)
Incontinence (urinary or faecal)
Prolapse (uterine, bladder, rectum, vaginal)
Breast health/breast feeding issues/mastitis
Did you have an Epidural during birth?
Nerve damage during birth (pudendal)
C-section wound discomfort or slow healing or ongoing numbness
Anaemia or taking iron tablets
Joint or muscle pain
Episiotomy cut or tears (degree if known)
Recent wounds (including c section)
Recent knee or hip replacement
Recently fitted bolts, pins
Notes or details for anything ticked above (for example: degree of tearing/ type of prolapse etc)
How would you describe your pelvic floor health?
Have you ever suffered a prolapse or pressure in the vagina/rectum? Do you leak urine when you exercise, sneeze, laugh, cough, or find it hard to hold in gas or urine?
Has your doctor ever advised that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when doing physical exercise? Do you suffer with asthma?
Is your doctor currently prescribing drugs for your blood pressure or a heart condition?
Do you have any old injuries (old broken bones, weaknesses, niggles, sore areas)?
Consult a GP or Women’s Health Physio before you start your new fitness regime. Drink lots of water throughout and after your workout. Please wear comfortable clothing that will enable you to exercise without restriction, including a good sports bra!
Risks and discomforts of training:
As with all exercise there is a risk of changes or injuries occurring during or following exercises including abnormalities in blood pressure/heart rate. Should you feel unwell or unsure please stop and rest, and consult a doctor if needed. I cannot be held responsible for any changes or injuries that may occur.
All information acquired will be treated as privileged and confidential information.
Unfortunately no refunds are given but you can cancel your subscription at any time.
By submitting this form you are agreeing to all of the above.
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