Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Have you ever been or are you currently pregant?

Yes

No

Is the problem related to pregnancy or childbirth?

Yes

No

Do you experience any of the following

Tick all that apply

Leaking of urine when you do not want it to

Increased urgency when needing to urinate

Having to urinating more than 8 times a day

Waking to urinate more than 1x at night

Pain with urination or when needing to urinate

A feeling of incomplete emptying with your bladder or bowel

Not being able to control or stop leakage of gas/wind/poo

Increased urgency when needing to pass a bowel movement

Straining or constipation

Painful bowel movements

A feeling of heaviness or dragging in your lower abdomen or pelvic region

Painful sexual intercourse or inability to have sexual intercourse

Other

Have you sought help from any of the following previously?

Physiotherapist

Doctor

Osteopath

Sport Therapist

Chiropractor

Other

Consent *

By ticking this box I consent to the general T+C’s and specifically consent to undertake an online assessment and treatment guided by a physiotherapist with Rehab Retreats Ltd.