Fitbump Intake Form

Fitbump Intake Form

Please fill out as much information as possible prior to joining classes to ensure we are all on same page and working out safely.
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth
Which class(es) are you signing up for?
How far pregnant or postpartum are you?
Number of pregnancies
Ages of Children
Number of vaginal deliveries
Number of C Sections
Did you require the use of forceps, vacuum assisted delivery, episiotomy ? Please list all interventions needed.
Epidural
Have you ever been to a Pelvic Floor Physiotherapist?
If yes - are you currently being treated or have you been cleared?
Have you experienced any of the following? If so please select all and elaborate in the text box below.
Elaborate on any pelvic floor dysfunctions or concerns here:
Have you ever been told you have a prolapse?
Do you suffer/have you suffered from postpartum depression?
Are you being treated for ppd?
What types of movement or exercise are you doing on a regular basis? Eg. Walking, yoga, strength training, parenting (lifting baby, toddler etc.)
What is your current fitness level?

Other
Please make us aware of any other injuries or health concerns.
How did you hear about Fitbump?

Other
Thank you for joining the Fitbump Family!
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