Emergency Contact
Name:: Tarryn McCullagh
Contact Phone Number:: 422198183
Relationship:: Wife
Why are you here?
What do you consider to be your number one priority?:: Weight Loss
Name two areas of your life which you are not happy with right now and would like to improve?:: Fintess and weight
What has kept you from starting an exercise program:: Procrastination, Family Commitments, Injury/Illness
Medical Backgrouund
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:
IS THERE A FAMILY HISTORY OF ANY OF THE ABOVE CONDITIONS? IF SO, PLEASE LIST THEM:: No
HAVE YOU HAD ANY ILLNESSES IN THE LAST 12 MONTHS? IF YES, PLEASE GIVE DETAILS: No
DO YOU HAVE ANY ALLERGIES?:: No
DO YOU HAVE ARTHRITIS, ASTHMA OR HERNIA?:: No
ARE YOU TAKING ANY PRESCRIBED MEDICATIONS? IF YES, PLEASE GIVE DETAILS?:: No
Are you receiving any treatment from a doctor, physiotherapist or other health professional? If Yes – What for?:: No
Have you been hospitalized recently or given birth in the last 3 months?:: No
NECK: NO
If YES, Please elaborate::
BACK: NO
If YES, Please elaborate::
SHOULDERS: YES
If YES, Please elaborate:: Right shoulder recon 2011
HIPS: NO
If YES, Please elaborate::
KNEES: YES
If YES, Please elaborate:: Left knee recon 1999 and minscus removal 2016
ANKLES: NO
If YES, Please elaborate::
Do you have any other medical problems or conditions we should know about prior to commencing an exercise program?:: NO
If Yes – please Elaborate::
I understand the questions above & my answers are true and correct. I will not have any claim against EPIC WIN PT or my instructor for any illness, injury or adverse change in medical condition arising directly/indirectly from any program carried out.:: I Agree