Postpartum Intake Questionnaire

Date
Date Format: MM slash DD slash YYYY
Client First Name*
Parent Name if client is a minor
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 I may go session by session, scheduled online or purchase discounted sessions as a package. The package may be pre-paid in office only with the sessions scheduled online using a special coupon code. There are no transfers, refunds or monetary value of sessions or coupon codes.
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I agree to give at least 24 hours' notice of rescheduling a appointment through the system. Cancellation of a session is to allow for future scheduling. There is no refund beyond three days of scheduling pre-purchased sessions. All pre-purchased sessions are valid for up to one year after purchase.
*
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.
*
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.
*
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. I also give my permission, allow communication on my, my minor/infant's behalf with our other health care providers.
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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/or health of my infant or minor and any resultant injury or mishap that may affect me, my pregnancy, my baby/s, my minor/s, and/or well being while participating in such program/s or session/s. In the event, I and/or my minor or infant 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.
*
I understand that results are not guaranteed.
Health History
Please select the one that applies*
- I am pregnant
- I am within the first year postpartum
- I am beyond the first year postpartum
- I have not had any children
- I am a man
- I am a minor Male or Female
How did you hear about Corrective Core & Musculoskeletal Health, LLC?*
What is your or your minor / infant's current age?*
Please enter a number less than or equal to 99.
What are your three main goals or concerns for seeing Julie?*
Below are intake questions for adults. If you are filling this out for a minor or infant please scroll to the bottom to proceed.
Do you have any diagnosis of any kind?
- Yes
- No
If yes, what is your diagnosis?
Have you had a surgeries and/or cesarean section?
- Yes
- No
What type of surgery? Oral, cosmetic, abdominal, joints, etc.
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
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
Do you ever need to get out of bed to urinate in the middle of the night?
- Yes
- No
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
Is there any history of bladder (UTI) or kidney infections?
- Yes
- No
How often do you have a bowel movement?
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)

Postpartum Intake Questionnaire

Release and Terms Form

Health History

Below are intake questions for adults. If you are filling this out for a minor or infant please scroll to the bottom to proceed.

Corrective Core Method & Baby Balance Method