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
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Month
-
Day
Year
Date
Name
First Name
Last 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
Yes
No
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.
Urinary incontinence - can include frequent urination, leakage with exercise or sneezing, urge to urinate etc.
Fecal incontinence
Painful sex
Low back pain
Pressure or pain in pelvic organs
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?
Beginner
Intermediate
Advanced
Other
Please make us aware of any other injuries or health concerns.
How did you hear about Fitbump?
Facebook
Instagram
Google
Word of Mouth
Mommy Connections
Other
Thank you for joining the Fitbump Family!
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