Postpartum Intake Questionnaire
Date Format: MM slash DD slash YYYY
Client First Name
Parent Name if client is a minor
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
French Southern Territories
Heard and McDonald Islands
Isle of Man
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Svalbard and Jan Mayen Islands
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Date Format: MM slash DD slash YYYY
Release and Terms Form
You must check to agree to all sections.
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.
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.
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.
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.
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.
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.
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
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?
If yes, what is your diagnosis?
Have you had a surgeries and/or cesarean section?
What type of surgery? Oral, cosmetic, abdominal, joints, etc.
Do you have an IUD or any other birth control surgically administered?
Are you presently or have you recently been under a doctor’s or PT care?
Do you have an umbilical hernia?
Do you have an inguinal hernia?
Have you had any surgical repairs of a hernia?
Was mesh used?
Have you had any laparoscopic surgeries?
Location and date?
Have you had an episiotomy?
Have you had tearing of the vaginal opening?
Do you experience pain with intimacy?
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?
Do you ever need to rush to the bathroom due to the sudden and/or strong urge to urinate or have a bowel movement?
Do you ever squat over a toilet to avoid sitting on the seat to urinate?
Is there any history of bladder (UTI) or kidney infections?
How often do you have a bowel movement?
Do you exercise regularly or participate in sports?
If so, what?
What is your current stress level?
Corrective Core Method & Baby Balance Method
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