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Personalised Program Enrolment Form
Enrolment form for personalised programs with Caren Van Gastel at Empower Me Fitness & Consulting. To be completed prior to your initial assessment.
These questions are a starting point to gain more information about you to enable a tailored and achievable program to be prescribed specifically for you & your circumstances.
The answers will be discussed in your initial assessment, or alternatively you can contact me on 0204 006 7441 to discuss.
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Email
*
Your email
Name
Your answer
Date of Birth (Month, Day, Year)
MM
/
DD
/
YYYY
Phone Number
Your answer
Address
Your answer
Occupation (prior to baby)
Your answer
Name and DOB of your Child/ren
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)
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
Are you currently pregnant? If yes, how many weeks?
Your answer
Delivery type (previous births)
Vaginal
Emergency C-section
Elective C-section
Clear selection
Any instruments used or complications from delivery?
Ventouse
Forceps
Large Tear (3rd or 4th degree)
Option 4
Postpartum hemorrhage
Infection
Don't know
Other:
How big was your baby at birth?
Your answer
What was your gestation age at delivery for your most recent birth?
Your answer
Are you still experiencing any bleeding post birth?
Yes
No
Clear selection
Are you currently breastfeeding?
Yes (fully)
Yes (partically)
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 & when it occurred
Your answer
What exercises/activity (if any) did you do whilst pregnant? How often?
Your answer
Have you done any exercises/activity since birth? If so, what and how often?
Your answer
Health & Fitness goals (General) - what would you like to get out of this program? e.g. improve fitness, build strength etc
Your answer
Health & Fitness goals (Specific) - what would you like to get out of this program? e.g. carry/lift baby pain free, run 5km, do 15 full push ups etc
Your answer
What time do you have available for exercise e.g. 30mins 3x/wk, 1hr 2x/wk, unlimited etc. In an ideal world, we would all have lots of time to exercise. In reality life gets in the way. What do you consider an achievable amount for you?
Your answer
What barriers are there that might stop you from exercising? e.g. lack of time, tiredness, injury, accessibility to equipment, competing demands from family etc
Your answer
Do you have any equipment available to use? e.g. swiss ball, dyna band, dumbbells, stairs
Your answer
What space do you have available to exercise in? e.g. lounge, bedroom, garage, backyard, park, gym etc
Your answer
What motivates you? e.g. reminder of goals, varied workouts, similar progressive workouts, rewards etc
Your answer
How did you hear about the Personalised program?
Your answer
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