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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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.
*
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.
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)
Corrective Core Method & Baby Balance Method
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