Step 1 of 7

  • Health History

    This questionnaire is to be completed by clients of all ages and genders. There will be questions that do not apply to you. Simply leave these blank. *Required Questions
  • Providing a cell number is very helpful during the COVID-19 pandemic so we can call you in your vehicle when you can come inside for your appointment.
  • MM slash DD slash YYYY
  • Please list the problem(s) that you would like to address with pelvic floor physiotherapy.
    Please help us understand any other pelvic floor issues, symptoms or dysfunction that you may be experiencing.