Emergency Contact

Name::

Contact Phone Number::

Relationship::

Why are you here?

What do you consider to be your number one priority?:: Weight loss to a healthy weight

Name two areas of your life which you are not happy with right now and would like to improve?:: How i feel about myself and my lack of self motivation

What has kept you from starting an exercise program:: Money, Lack of Motivation, Zombies

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:: None

HAVE YOU HAD ANY ILLNESSES IN THE LAST 12 MONTHS? IF YES, PLEASE GIVE DETAILS: No

DO YOU HAVE ANY ALLERGIES?:: Birds- no joke

DO YOU HAVE ARTHRITIS, ASTHMA OR HERNIA?:: No

ARE YOU TAKING ANY PRESCRIBED MEDICATIONS? IF YES, PLEASE GIVE DETAILS?:: None

Are you receiving any treatment from a doctor, physiotherapist or other health professional? If Yes – What for?:: None

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: NO

If YES, Please elaborate::

HIPS: NO

If YES, Please elaborate::

KNEES: NO

If YES, Please elaborate::

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

BODY COMPOSITION + POSTURAL APPRAISAL CONSENT
Posture & Body Composition: I Agree
CONDITIONS OF TRAINING
THIS IS AN IMPORTANT DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS AND OBLIGATIONS. PLEASE READ CAREFULLY AND DO NOT SIGN UNLESS YOU UNDERSTAND IT. IF YOU HAVE ANY QUESTIONS, PLEASE ASK.:
LEGALLY BINDING AGREEMENT: I Agree