Empower Me Fitness Classes Enrollment Form
Enrollment form for Mums & Bubs classes with Caren Van Gastel at Empower Me Fitness & Consulting.
First time enrolment? - please answer all questions.
Returning for another term? - please confirm preferred class time and update any details as required.
Which class are you enrolling in?
Tuesday Morning 9:30am - Mums & Bubs (Mornington) (4 spaces remaining)
Tuesday Morning 10:15am - Mums & Bubs (Mornington) (FULL)
Date of Birth
Emergency contact name & phone number
Occupation (prior to baby)
Name and DOB of your Child/ren
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?
Delivery type (previous births)
Any instruments used or complications from delivery?
Large Tear (3rd or 4th degree)
How big was your baby at birth?
What was your gestation age at delivery for your most recent birth?
Are you still experiencing any bleeding post birth?
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 & 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) did you do whilst pregnant? How often?
Have you done any exercises/activity since birth? If so, what and 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 these Mums & bubs classes?
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