PORT - Empower Me Fitness Classes Enrollment Form
Enrollment form for Exercise classes with Caren Van Gastel at Empower Me Fitness & Consulting
Email address *
Name
Date of Birth
MM
/
DD
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YYYY
Phone Number
Address
Occupation
Have you ever had or do you have?:
Are you currently pregnant? If yes, how many weeks?
If pregnant, do you experience Pelvic Girdle pain or symphasis pubis dysfunction?
Clear selection
Are you currently breastfeeding?
Clear selection
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:
Have you seen, or are you seeing a Women's Health/Pelvic health physio for any of the above?
Clear selection
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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