Postpartum Intake Questionnaire

Date
Date Format: MM slash DD slash YYYY
First Name*
Last Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell*
DOB*
Date Format: MM slash DD slash YYYY
Referred by
Release and Terms Form
You must check to agree to all sections.
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I understand that discounted sessions package pre-payment is due at the time of initial session unless I wish to continue session by session or decide to not continue.
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I agree to give at least 24 hours' notice of cancellation or reschedule of appointment.
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I agree to forfeit pre-purchased session upon second cancellation or reschedule with less than a 24-hour notice.
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I understand that Corrective Core & Musculoskeletal Health, LLC provides neither medical nor psychotherapy or physical therapy services, and the session is not a substitute for medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.
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I understand that Julie Jetzer LMBT, CPT is not a Physical Therapist and does not work with injuries. She would be happy to recommend one or more area Physical Therapists if that is the care I am looking for.
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I have stated all my known conditions along with surgeries and will take it upon myself to keep Corrective Core & Musculoskeletal Health LLC updated on my health changes.
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I understand that I should consult my physician or other healthcare practitioners before starting any exercise program about my current health, any medications I am taking, and supplements I plan to take during my program/s or session/s offered by Corrective Core & Musculoskeletal Health, LLC. Nothing stated or posted by Julie Jetzer, Corrective Core & Musculoskeletal Health, LLC, or Blossom Tree Wellness, LLC co-op partners and/or affiliates' services are intended to be, and must not be taken to be, the practice of medicine and/or medical advice, and/or care and they shall not be liable for any liability of any kind resulting from the use of any program/s or session/s in office or outside of set office appointments.
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I give my permission, for my therapist, Julie Jetzer, of Corrective Core & Musculoskeletal Health, LLC, to take notes, photos and videos, including health history/ medical and /or personal information I choose to disclose to her.
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I accept full responsibility for participating in any Corrective Core & Musculoskeletal Health, LLC program/s or session/s and agree to communicate any and all physical discomforts or problems to my doctor/midwife and Julie Jetzer, owner of Corrective Core & Musculoskeletal Health, LLC. I accept all responsibility for my health and any resultant injury or mishap that may affect me, my pregnancy, my baby/s and/or my well being while participating in such program/s or session/s. In the event, I suffer any injury or discomfort while participating in or resulting, directly or indirectly, from my participation in this program/s session/s, I hereby waive any and all claims relating to such injury or discomfort against Julie Jetzer LMBT, CPT, Corrective Core & Musculskeletal Health, LLC and any of their respective agents or affiliates.
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I understand that results are not guaranteed.
Health History
How did you hear about Corrective Core & Musculoskeletal Health, LLC?
Current Age?
Please enter a number less than or equal to 99.
How long are you postpartum (weeks)?
Please enter a number less than or equal to 99.
How many pregnancies have you had?
Please enter a number less than or equal to 10.
How many deliveries?
Please enter a number less than or equal to 10.
What are your three main goals or concerns for seeing Julie?
Do you have any diagnosis of any kind?
- Yes
- No
If yes, what is your diagnosis?
Are you currently trying to get pregnant?
- Yes
- No
Are you hoping to become pregnant in the future?
- Yes
- No
Have you had a cesarean section?
- Yes
- No
How many?
What date(s)?
Any VBAC (vaginal birth after cesarean)?
- Yes
- No
Why?
Location of deliveries? (hospital, birth center, home, one or more of these locations, don’t wish to disclose?)
Do you have an IUD or any other birth control surgically administered?
- Yes
- No
Are you presently or have you recently been under a doctor’s or PT care?
- Yes
- No
Do you have an umbilical hernia?
- Yes
- No
Do you have an inguinal hernia?
- Yes
- No
Have you had any surgical repairs of a hernia?
- Yes
- No
Was mesh used?
- Yes
- No
Have you had any laparoscopic surgeries?
- Yes
- No
Location and date?
Have you had an episiotomy?
- Yes
- No
Details?
Have you had tearing of the vaginal opening?
- Yes
- No
Severity?
- Stage 1
- Stage 2
- Stage 3
- Stage 4
- Unknown
Do you experience pain with intimacy?
- Yes
- No
Is it pain during penetration?
- Yes
- No
Is it a deep thrusting pain?
- Yes
- No
Does it pass quickly or change to a dull pain?
- Passes quickly
- Changes to dull pain
- Neither
Do you leak urine during activities such as laughing, coughing, sneezing, running or jumping?
- Yes, a little
- Yes, a lot
- No, I do not leak urine
If so, how often?
Do you use any device to prevent these types of leaks?
Please describe.
Do you ever need to get out of bed to urinate in the middle of the night?
- Yes
- No
If so, how often?
Do you ever need to rush to the bathroom due to the sudden and/or strong urge to urinate or have a bowel movement?
- Yes
- No
Do you ever squat over a toilet to avoid sitting on the seat to urinate?
- Yes
- No
If so, how often?
Is there any history of bladder (UTI) or kidney infections?
- Yes
- No
If so, at what age?
How often do you have a bowel movement?
Have you ever had...
- IBS
- Constipation
- Other gastro issues
- None of the above
Do you exercise regularly or participate in sports?
- Yes
- No
If so, what?
How often?
What is your current stress level?
- 0 (low)
- 1
- 2
- 3
- 4
- 5 (high)
Is the source of your stress...
- Positive
- Negative
- Both
On average, how many hours do you sleep each night?
Please enter a number from 0 to 24.
Do you usually wake feeling...
- Rested
- Tired
I feel anxious...
- Never
- Rarely
- Ocassionally
- Often
I feel sad or depressed...
- Never
- Rarely
- Ocassionally
- Often
Please list any allergies you have.
Menstrual Pattern
Check all that apply
- Painful periods
- Late, early, or irregular (typical cycle should be 28 days)
- Dark, thick blood at onset or end of menstruation
- Excessive bleeding (more than one pad per hour)
- Blood clots during menstruation
- PMS/Depression with or before period
- Failure to ovulate regularly
- Painful ovulation
How many days in your cycle now?
Please enter a number from 0 to 31.
Breastfeeding Pattern
Check all that apply
- I am breastfeeding
- Baby is 100% breastfed
- I need to pump in between feedings
- Breastfeeding is painful
- I have experienced or currently have stuck milk ducts
- I have experienced or am currently experiencing mastitis
- I am under doctor care for mastitis
- antibiotics have been prescribed
- I am working with a Lactation Consultant
My baby has been assessed for a tongue and/or lip tie
- Yes
- No
Findings of assessment?
Did your baby have a revision?
- Yes
- No
Who performed the revision?
When was the revision performed?
Date Format: MM slash DD slash YYYY

Postpartum Intake Questionnaire

Release and Terms Form

Health History

Menstrual Pattern

Breastfeeding Pattern