PORT - Empower Me Fitness Classes Enrollment Form
Enrollment form for Exercise classes with Caren Van Gastel at Empower Me Fitness & Consulting
Date of Birth
Have you ever had or do you have?:
High Blood Pressure
Liver or Kidney condition
Regular Muscle Cramps
Recent Major Surgery (if yes, explain in Injuries section)
Heart condition or murmer
Palpitations or pains in chest or breathing difficulties brought on by exercise
Dizziness or fainting
A family history of heart disease, stroke, high blood pressure or raised cholesterol
Any bone or joint problem that could be aggravated by physical activity (if yes, explain in injury section)
Are you currently pregnant? If yes, how many weeks?
If pregnant, do you experience Pelvic Girdle pain or symphasis pubis dysfunction?
Are you currently breastfeeding?
Are you on any prescribed medication? If yes, what and how often?
Do you have any current/previous injuries? If yes, please provide details of the injury and when it occurred.
Pelvic Health - Do you experience any of the following:
accidentally leaking urine during exercise, laughter, coughing or sneezing
urgency to go to the toilet
constantly needing to go to the toilet
finding it difficult to empty the bladder or bowel
accidentally losing control of the bladder or bowel
a bulge in the vagina or a feeling of heaviness, discomfort, pulling, dragging or dropping
pain in the pelvic area
Have you seen, or are you seeing a Women's Health/Pelvic health physio for any of the above?
What exercises/activity (if any) do you currently do? How often?
Health & Fitness goals - what would you like to get out of these classes?
What type of exercises do you love to do?
What type of exercises do you dislike doing?
How did you hear about this class?
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