Your Info

First Name *

Last Name *

Phone *

Email *

Your goals

If weight loss, how much would you like to lose?

1-5 kg's

6-10 kg's

11-15 kg's

15 Plus kg's

Medical Clearance

Have you received clearance from your doctor to resume exercise after childbirth? *

Yes

No

If yes, please provide the date of the clearance.

Have you received clearance from a physiotherapist for postpartum exercise? *

YES

NO

If yes, please provide the date of the clearance received.

Postpartum Health

How long has it been since you gave birth ? *

Less than 12 weeks

12 weeks or more

Were there any complications during pregnancy, delivery, or postpartum? (E.g., C-section, preeclampsia, etc.) *

Yes

No

If yes, please provide details.

Are you currently experiencing any postpartum symptoms such as pain, incontinence, or pelvic floor issues? *

Yes

No

If yes, please provide details.

Physical Fitness & Health

Did you exercise regularly before or during your pregnancy? *

Yes

No

Are you currently breastfeeding? *

Yes

No

Are you experiencing any back pain, pelvic pain or any other injuries? *

Yes

No

If yes, please give details.

Do you have any existing medical conditions that may affect your ability to exercise? (E.g., high blood pressure, diabetes, etc.) *

Yes

No

If yes, please give details.

Pelvic Floor & Abdominal Recovery

Have you been diagnosed with diastasis recti (abdominal separation)? *

Yes

No

If yes, what is your current stage and what treatment are you receiving?

Have you experienced any pelvic floor dysfunction (e.g., urinary incontinence, pelvic organ prolapse)? *

Yes

No

If yes, please explain.

Exercise Readiness

Do you feel ready to participate in moderate-intensity exercise? *

Yes

No

Are you aware of any other reasons that might prevent you from safely exercising? *

Yes

No

If yes, please explain.

Consent & Liability

Do you agree to consult your doctor or physiotherapist if you experience any pain or discomfort during the class? *

Agree

I acknowledge that I am responsible for ensuring I am medically fit to participate and will inform the trainer of any concerns. *

Agree

I acknowledge that I am participating in this class at my own risk. *

Agree