Start Your Free Intake

First name

Email

Country

Province, state or region (optional)

Your age

How did you hear about Pelvactiv? (optional)

Pelvactiv works with adults. If you're under 18, please ask a parent or guardian to email us.

Where are you with an endometriosis diagnosis?

Any other diagnoses? (optional)

How long have you had symptoms?

Surgeries for endometriosis

None123 or more

Year of your most recent surgery (optional)

What are you using now? (optional)Choose all that apply.

Have you seen a pelvic floor physiotherapist before?

Yes, currentlyYes, in the pastNo

Do you have a period right now?

Typical cycle length in days (optional)From the first day of one period to the next.

First day of your last period (optional)Helps us place you in your cycle.

Which phase is usually hardest? (optional)

These answers are your starting point. We'll ask the same questions at the middle and end of the program, so you can see what changed.

Your average pain over the past 7 days

0 = no pain10 = worst imaginable

Your worst pain over the past 7 days

0 = no pain10 = worst imaginable

Your average energy over the past 7 days

1 = exhausted10 = full energy

Where do you feel pain?Choose all that apply.

What does it feel like? (optional)Choose all that apply.

Digestive symptoms (optional)

Bladder symptoms (optional)

Mood and nervous system (optional)

Pain with sex (optional)

In the past month, on how many days did pain stop or limit work, school or plans?

What would you most like to change? (optional)

What are you interested in?

Anything else we should know? (optional)

Consent I've read the privacy notice. I agree to Pelvactiv storing my answers to plan my coaching, and I understand this is coaching, not medical care. Optional: Pelvactiv may use my answers, with my name and email removed, to measure how well the program works. This doesn't affect my place or price, and I can withdraw at any time. Optional: send me occasional emails about Pelvactiv.

Thank you. Your intake is in.