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Once you have completed this form and confirmed you have no contraindications to using the PelviPower chair, you can go ahead and book your free trial.

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FAQ about the screening form 

PelviPower Screening, Information Gathering, Understanding, & Consent Form

Please double-check that your email address is correct, as it can affect this form being submitted correctly.

Birthday
Day
Month
Year
Have you completed a PelviPower screening form with us before?
No – this is my first enquiry
Yes - I am an existing client and updating my details
Yes - but it was a long time ago, so please treat this as a fesh enquiry
Other

SREENING

PelviPower Contraindication Check

Please read each point carefully and select Yes or No.

  • If you select Yes for any item, the PelviPower chair is NOT suitable for you at this time, and we will discuss alternative options to support you.


  • If you select No, you are confirming that the item does not apply to you and agree that the PelviPower chair is a safe and appropriate treatment method for you.

Please confirm your biological gender.
Female
Male

This then opens up a few more specific questions for you, depending on your biological gender.

Do you have METAL in your spine, pelvis, hips, or upper leg?
Yes
No
Do you have a bladder pacemaker, cardiac pacemaker, or any implanted electronic device?
Yes
No
Do you use an insulin pump?
Yes
No
Do you have an implanted defibrillator?
Yes
No
Do you have a neurostimulator?
Yes
No
Do you have decompensated heart disease or irregular heart rhythms/arrhythmias, or any unmanaged or unstable heart conditions?
Yes
No
Do you have epilepsy?
Yes
No
Do you currently have active cancer, are you undergoing investigation or treatment for cancer, or are you currently being monitored or treated for pre-cancerous cells (including skin cancer)?
Yes
No
Do you have any old tattoos (typically from the 1960s–1970s) on your lower torso, pelvic area or upper thigh?
Yes
No
Do you have any piercings or metal jewellery or metal underwear in the pelvic or genital area — that you cannot remove for all your PelviPower sessions?
Yes
No
Have you had recent surgery (< 6 weeks)?
Yes
No
Have you had pelvic surgery that included metal mesh or tape?
Yes
No
Do you have cochlear implants?
Yes
No
Do you wear hearing aids — that you CANNOT REMOVE during your PelviPower sessions?
Yes
No
Do you take blood-thinning medication?
Yes
No
Do you have an acute urinary tract infection (UTI)?
Yes
No
Do you currently have PAINFUL haemorrhoids?
Yes
No
Do you currently have an infection with a fever?
Yes
No
Final confirmation for contraindications. Do any of the above contraindications apply to you?
Yes
No
  • If you select Yes, PelviPower chair is NOT suitable for you at this time.


  • If you select No, you are confirming that none of the contraindications apply to you, and agree the PelviPower chair is suitable for you.

INFORMATION GATHERING

Have you ever been diagnosed with, or told you may have, a pelvic organ prolapse?

Movement & Performance

PelviPower supports pelvic floor function alongside core coordination and hip stabiliser strength. This can contribute to improved control, balance, and load management during sport and dynamic movement.

Do any of the following apply to you?
Have you used PelviPower before?
Yes
No
Please tick the area(s) that you feel are relevant to you right now (select as many as you wish).

Please only list one thing.

Example:

"Stop leaking when walking the dog"

"Stop leaking when sneezing & coughing"

"Feel strong for my skiing holiday"

"Reduce my back pain"

"Reduce my pelvic pain"

"Improve my prolapse symptoms"

"Less trips to the toilet"

"Sport- injury prevention"

Here you can list the other things that matter to you/that you can work on whilst addressing your number one goal.

Out of 10 (with 1 being the least problematic and 10 being the most problematic), what would you score your current issues linked to your number ONE goal?
1
2
3
4
5
6
7
8
9
10

Consider this example when answering:

  • My back pain is currently a 6/10

We would like to ask you this question again after using the PelviPower chair, and we hope to see the number reduced.

So...

  • My number ONE goal is to improve my back pain.

  • It started at a 6/10

  • It's now a 5/10

Physio?

Medication?

Nothing?

?

UNDERSTANDING

Please tick each statement to confirm your understanding:

Eligibility
I understand that I can only use PelviPower if I have no contraindications.
What PelviPower Is
I understand that PelviPower is a muscle training programme designed to improve pelvic floor function, coordination, and strength, as well as my core and deep hip stabilisers. It may also help release tight muscles. Like all physical training, results build gradually over time and rely on consistency, appropriate intensity, and listening to my body.
Training Frequency
I understand that muscles adapt through regular training. I may be advised to use PelviPower once, twice, or up to three times per week, depending on my needs. Optimal frequency varies from person to person.
Rest & Recovery
I understand that I should allow at least one rest day between sessions to support recovery and effective progress.
Function Along With Strength
I understand the importance of building function along with strength, including coordination, control, and the ability to both activate and relax my pelvic floor. Some pelvic floor issues are related to function rather than strength, and both are important for long-term improvement.
Programme Options
I understand that PelviPower at Harris Mind & Body offers programmes across six main training areas, and that the HMB team will guide me to the most appropriate starting point and pathway based on my individual needs.
  • Incontinence

  • Women’s Health

  • Men’s Health

  • Back

  • Release

  • Fitness

Programme Reviews
I understand that if I would like a review of my PelviPower programme, I can book a Programme Review at any time. These reviews provide dedicated time to check progress, adjust settings, and ask questions. Programme reviews are optional, bookable as needed, and carry an additional cost.
Electronic Devices & Personal Items
I understand and will remove and place personal items such as phones, smart watches, smart rings, earphones, keys, wallets, and cards at least 0.5 metres away from the PelviPower chair during use, as the electromagnetic field may interfere with or damage electronic devices.
External Metal (Clothing & Jewellery)
I understand that small amounts of external metal (such as clothing buttons, zips, underwire bras, or dental braces) are safe and/or outside the PelviPower chair’s field of activity. BUT metal items worn directly within the seated treatment area (for example, metal in underwear in direct contact with the chair & sensitive skin) are not suitable and should be avoided.

CONSENT

Informed Consent for PelviPower Training

Please tick each box to confirm your understanding and consent:

Contraindications
I confirm that I have completed the Contraindication Checks honestly and to the best of my knowledge, and I understand that PelviPower is not suitable for me if any contraindications apply.
Understanding the Training
I understand that PelviPower uses electromagnetic stimulation delivered through a seated chair to activate and train the pelvic floor, deep core, and hip stabilising muscles while I remain fully clothed.
Sensations & Effects
I understand that PelviPower is a safe muscle training method and that, like any form of physical training, it may cause temporary sensations such as warmth, muscle engagement, mild tenderness, or a post-exercise feeling.
Complementary Method
I understand that PelviPower is a complementary training method and does not replace medical diagnosis, investigation, or treatment by a doctor, specialist, or therapist.
Ongoing Medical Responsibility
I understand that I remain responsible for seeking medical advice, investigation, or treatment from my GP, physio, or healthcare professional for any symptoms, concerns, or changes in my health.
Changes in Health
I agree to inform Harris Mind & Body (HMB) in writing if my health changes in a way that may affect the suitability or safety of PelviPower training.
Voluntary Participation
I understand what PelviPower training involves and am happy to proceed.
Consent to Data Processing (GDPR)
I consent to Harris Mind & Body securely storing and processing my personal information for the purposes of administering PelviPower training, contacting me about my sessions, and ensuring my safety.
Best times for my free trial (please tick all that apply)
My preferred method(s) of contact:
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What happens now:
 

How to book your FREE TRIAL session:

  • We will call or email you to arrange your FREE trial booking once we receive your screening form, and we can confirm whether the chair is suitable for you.

  • You are very welcome to chat with us in the clinic.

  • You can also call us on 01635 44882 — great if you are super keen to book something asap.

  • You can email us (details below).

FAQ / Extra Information to Support Your PelviPower Screening Form
 

This page is designed to help you understand some of the screening questions you are asked before using the PelviPower chair.

If anything here feels unclear or you’re unsure how it applies to you, please speak to us or check with your GP before proceeding.

 

Pregnancy & Trying to Conceive

PelviPower uses electromagnetic stimulation and is not suitable during pregnancy or if you are actively trying to conceive.


Coil / IUD

PelviPower can usually be used by individuals with an IUD/coil. However, as it uses electromagnetic stimulation, we cannot guarantee that the position of the IUD will remain unchanged. In rare cases, this could affect contraceptive effectiveness.

If you rely on an IUD for contraception, we recommend:

  • Using additional contraception during PelviPower training, and

  • Having your IUD checked by your GP or practice nurse before relying on it again.
     

Metal Inside the Body

We are concerned about metal inside the body and within the PelviPower chair’s seated treatment area.

Examples include:

  • Spinal or hip implants

  • Knee replacements within 10 cm above the knee (most knee replacements are fine, as they do not sit this high)

  • Metal clips, screws, rods, or wires in the pelvis or spine

If you are unsure whether your implant falls within the treatment area, please check with us or your GP.
 

Electronic Implants & Devices

PelviPower may interfere with electronic implants or devices, including:

  • Cardiac pacemakers or defibrillators

  • Neurostimulators

  • Insulin or medication pumps

  • Cochlear implants (some models require medical clearance)

If you have any implanted electronic device, the PelviPower chair is not suitable for you.
 

Heart Conditions

The stimulation may place additional demand on the cardiovascular system and could interfere with unstable heart rhythm control. PelviPower should only be considered once a heart condition is stable and appropriately managed. Well-managed heart conditions are generally suitable. If unsure, please check with your GP.
 

Epilepsy

Magnetic stimulation may increase seizure risk. If you have epilepsy, PelviPower is not recommended unless you have been medically cleared.
 

Cancer & Pre-Cancerous Conditions

PelviPower increases circulation and cellular activity. As a precaution, and because large-scale medical trials are not possible in this area, there is currently insufficient evidence to confirm the safety of electromagnetic stimulation for individuals with:

  • Active cancer

  • Recent cancer treatment

  • Current pre-cancerous conditions

  • Ongoing cancer investigation

This applies to all cancer types, including skin cancers.
 

If you have previously had cancer or pre-cancerous cells and have been medically discharged from care, PelviPower is generally considered suitable. As a general guideline, being medically cleared and out of follow-up for 5 years is commonly regarded as the gold standard for no longer being within a monitoring period. If unsure, please check with your GP before proceeding.


Tattoos

We are only concerned about tattoos within the seated treatment area, and only very old tattoos (typically from the 1960s–1970s, often done outside the UK). Older inks sometimes contained heavy metals (such as lead), which may react to magnetic fields. Modern, regulated tattoos are absolutely fine and are not a contraindication.
 

External Metal (Clothing & Jewellery)

Metal jewellery, piercings, and menstrual underwear containing metal fibres must be removed before treatment, as metal can warm slightly during magnetic stimulation and this is the main area of activity. Small amounts of metal elsewhere (such as buttons, zips, underwire bras, or dental braces) are generally fine, as they sit outside the field of activity.
 

Recent Surgery

Your body needs time to heal before using PelviPower safely. Recent surgery may mean PelviPower is temporarily unsuitable.
 

Mesh / Tape Surgery

Healing tissues and surgical materials can be affected by magnetic stimulation, particularly if any part contains metal. Most modern mesh and tape procedures use synthetic (non-metal) materials, which are fine once fully healed. If you are unsure what material was used or whether healing is complete, please check with your GP.
 

Hearing Aids

Hearing aids should be removed during treatment due to the magnetic field. If you can remove them, please do so and leave them on the table away from the chair during your session.
 

Blood-Thinning Medication

This question refers to prescribed blood-thinning or anticoagulant medication (for example, warfarin, apixaban, rivaroxaban, dabigatran, or similar). Most people taking blood-thinning medication can use PelviPower safely. However, increased circulation may increase the risk of bruising or tenderness for some individuals. Please check with your GP before proceeding.

Urinary Tract Infection (UTI)

PelviPower should not be used if you currently have a UTI. The stimulation can increase pelvic floor activity and local blood flow, which may worsen irritation or discomfort. Treatment should resume only once the infection has fully cleared.
 

Painful Haemorrhoids

PelviPower should not be used if you have painful haemorrhoids, as sitting on the chair and muscle stimulation can increase pressure and blood flow in the area. Please wait until symptoms have settled before resuming treatment.
 

Fever or Acute Illness

If you have a fever or are feeling unwell, your body needs rest. PelviPower is not recommended until you are fever-free and feeling better.

History of prostate surgery or procedures

Prostate surgery can significantly affect pelvic floor muscles and the nerves that control bladder and sexual function. Men may experience weakness, reduced coordination, or altered sensation. This is directly relevant to PelviPower because neuromuscular stimulation can support pelvic floor retraining, but treatment plans may need to be adapted based on surgical history.

 

Prostate enlargement (BPH) or prostatitis​

Conditions affecting the prostate can alter bladder emptying, urgency, and pelvic muscle tension. Chronic prostatitis can also be associated with pelvic pain and overactivity of pelvic floor muscles. Understanding this helps determine whether PelviPower should focus on strengthening, relaxation, or coordination rather than pure power.

Urinary leakage or reduced bladder control

Urinary symptoms are a key indicator of pelvic floor dysfunction. They help identify whether pelvic floor weakness, poor timing, or fatigue may be present. PelviPower is often used specifically to improve pelvic floor strength and neuromuscular control if you are experiencing these symptoms.

Erectile difficulties or changes in sexual function

Sexual function is closely linked to pelvic floor muscle strength, endurance, and coordination, as well as blood flow and nerve supply. Changes here can indicate reduced pelvic floor engagement or neuromuscular efficiency, making this highly relevant when considering PelviPower as part of a rehabilitation or performance pathway.

Testicular, perineal, or pelvic discomfort

Pain or discomfort in these areas can be associated with pelvic floor overactivity, nerve sensitivity, or muscle guarding. This is important to know because PelviPower may need to be introduced cautiously, or combined with relaxation and manual strategies rather than high-intensity stimulation.

Cycling-related pelvic discomfort or numbness

Prolonged cycling can place pressure on the perineum and pudendal nerves, potentially affecting sensation, blood flow, and pelvic floor coordination. Identifying this helps determine whether symptoms may be load-related and whether PelviPower is being used to restore neuromuscular function or support recovery.

Low testosterone diagnosed or under investigation

Testosterone plays a role in muscle mass, strength, and recovery, including the pelvic floor. Low levels may influence how effectively muscles respond to training, including electromagnetic stimulation. This information helps set realistic expectations and tailor progression when using PelviPower.

Pregnancy history

Pregnancy places significant load on the pelvic floor muscles, connective tissue, and supporting structures, including if delivery was by caesarean section. Understanding pregnancy history helps identify potential contributors to pelvic floor weakness, reduced endurance, or altered coordination, all of which are relevant when considering PelviPower.

Mode of delivery (vaginal birth / assisted birth / caesarean section)

Different modes of delivery place different stresses on the pelvic floor. Vaginal and assisted births may involve muscle stretch, nerve compression, or perineal trauma, while caesarean sections can still affect core and pelvic coordination through abdominal surgery. This information helps guide how PelviPower is introduced and progressed.

Perineal trauma, tearing, or episiotomy

Perineal injury can influence muscle integrity, scar sensitivity, and neuromuscular control. This is important when using PelviPower, as stimulation parameters and progression may need to be adjusted to ensure comfort and effective recruitment of the pelvic floor.

Birth-related trauma or prolonged labour

Prolonged or difficult labour can contribute to pelvic floor fatigue, nerve stretch, and long-term changes in muscle function. Identifying this helps determine whether PelviPower should focus on gentle reactivation, coordination, or graded strengthening rather than high-intensity stimulation initially.

Onset of symptoms following pregnancy or childbirth

Knowing when symptoms such as leaking, heaviness, or reduced control began helps clarify whether they are likely related to childbirth, hormonal changes, or other factors. This guides clinical reasoning and helps set realistic expectations for PelviPower outcomes.

Pelvic pain or discomfort

Pelvic pain may indicate overactivity, muscle guarding, or altered neuromuscular patterns rather than weakness alone. This is relevant to PelviPower because some individuals may benefit from coordination and relaxation work before or alongside strengthening.

Hormonal factors (including perimenopause and menopause)

Hormonal changes can affect tissue quality, muscle strength, and recovery. Reduced oestrogen levels may influence how pelvic tissues respond to loading and training. This context is important when planning PelviPower frequency, intensity, and progression.

Gynaecological surgery

Procedures such as hysterectomy or prolapse repair can alter pelvic support structures and neuromuscular control. Understanding surgical history helps ensure PelviPower is used safely and appropriately within an individual’s recovery or long-term management plan.

Pelvic organ prolapse (bladder, bowel, uterine or rectal)

Pelvic organ prolapse involves a change in the support of the pelvic organs due to alterations in muscle, connective tissue, or nerve function. This can influence symptoms such as heaviness, bulging, or reduced pelvic control. Prolapse is relevant to PelviPower because treatment may need to focus on improving pelvic floor coordination, support, and endurance, with careful consideration of symptom response and progression.

​​

How is PelviPower relevant for athletes?

PelviPower supports pelvic floor function alongside deep core coordination and hip stabiliser activation. Together, these systems play a key role in how force is transferred through the body during running, cutting, jumping, rotation, and change of direction. For athletes, this can influence control, efficiency, balance, and resilience under load.

Which sports can benefit from PelviPower?

PelviPower can be relevant for a wide range of sports, particularly those involving impact, speed, or rotational demands, such as running, football, skiing, rugby, tennis, hockey, cycling, and gym-based training. It can also be helpful for athletes who cross-train or compete in multiple disciplines.

Is PelviPower just for injury rehabilitation?

No. While PelviPower can support rehabilitation, it is also used as part of performance optimisation. Athletes may use it to improve core–pelvic coordination, enhance stability during high-load movements, and support efficient movement patterns, even when no injury is present.

Can PelviPower help with balance and control?

Yes. The pelvic floor works closely with the deep core and hip stabilisers to provide a stable base for movement. Improved coordination in this system can support balance, postural control, and confidence during dynamic tasks such as sprinting, landing, and changing direction.

Does PelviPower help with injury prevention?

PelviPower may contribute to injury prevention by supporting better load management through the pelvis, hips, and trunk. Improved neuromuscular coordination can reduce compensatory patterns that sometimes contribute to recurring injuries, particularly in the hips, groin, lower back, and hamstrings.

Is PelviPower suitable during return-to-sport phases?

PelviPower can be useful during return-to-sport phases, as it allows targeted neuromuscular activation without joint loading. This can complement field-based training and gym work, helping athletes rebuild control and confidence as training intensity increases.

Do athletes still need to train normally?

Yes. PelviPower is not a replacement for sport-specific training, strength work, or conditioning. It is designed to complement existing training by supporting the deep systems that underpin efficient movement and performance.

Is PelviPower suitable for both male and female athletes?

Yes. PelviPower is suitable for both male and female athletes. Pelvic floor and deep core function are essential for performance in all bodies, and assessment helps ensure PelviPower is used appropriately for individual goals and training demands.

Why is PelviPower useful for preparing for a ski holiday?

Skiing places high demands on pelvic stability, core coordination, and hip control, particularly during long days, repeated turns, and variable terrain. PelviPower supports the deep pelvic floor, core, and hip stabiliser muscles that contribute to balance, control, and efficient movement, and by supporting neuromuscular coordination and muscular endurance, it may help skiers maintain better movement quality as fatigue develops and form part of a broader approach to preparing the body for skiing-related demands.

Why is PelviPower useful within a back pain, piriformis, or sciatica-focused programme?

Piriformis-related pain and sciatica-type symptoms are often influenced by how the pelvis, deep core, and hip stabiliser muscles coordinate and manage load around the lower spine and hip region. PelviPower supports the deep pelvic floor, core, and hip stabiliser muscles that contribute to pelvic and spinal control, and by supporting neuromuscular coordination and muscular endurance, it may help improve movement quality and reduce unnecessary strain as part of a broader programme for managing back, piriformis, or sciatica-related symptoms alongside appropriate clinical care.

Send us a message - PelviPower Trial

I confirm I have completed my PelviPower Screening Form, have no contraindications, and am ready to book my FREE PelviPower Trial.
YES - I'm ready to book!
Not yet — I have more questions
I do have a contraindication(s), but I would like to explore other ways that you can help me.
I would prefer you to contact me via:
Telephone
Email
When I am next in the clinic

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Business: Harris Healthcare Solutions Ltd

Registered Company Number: 05783225

Harris Mind & Body (HMB) 

Physio & Pilates: Clinic & Studio

01635 44882​​

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