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PORT - Empower Me Fitness Classes Enrollment Form
Enrollment form for Exercise classes with Caren Van Gastel at Empower Me Fitness & Consulting.
Classes will be held on Wednesday evenings at 6pm at Sawyers Bay School. The cost is $100 per term.
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Email
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Your email
Name
Your answer
Date of Birth
MM
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DD
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YYYY
Phone Number
Your answer
Address
Your answer
Occupation
Your answer
Have you ever had or do you have?:
High Blood Pressure
High Cholesterol
Diabetes
Epilepsy
Liver or Kidney condition
Arthritis
Asthma
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?
Your answer
If pregnant, do you experience Pelvic Girdle pain or symphasis pubis dysfunction?
Yes
No
Not sure
Clear selection
Are you currently breastfeeding?
Yes
No
Clear selection
Are you on any prescribed medication? If yes, what and how often?
Your answer
Do you have any current/previous injuries? If yes, please provide details of the injury and when it occurred.
Your answer
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
painful sex
Have you seen, or are you seeing a Women's Health/Pelvic health physio for any of the above?
Yes
No
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What exercises/activity (if any) do you currently do? How often?
Your answer
Health & Fitness goals - what would you like to get out of these classes?
Your answer
What type of exercises do you love to do?
Your answer
What type of exercises do you dislike doing?
Your answer
How did you hear about this class?
Your answer
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