Emergency Contact

Name:: JB Hewitt

Contact Phone Number:: 408220913

Relationship:: Husband

Why are you here?

What do you consider to be your number one priority?:: Not look permanently 6M pregnant.

Name two areas of your life which you are not happy with right now and would like to improve?:: more sleep. more energy.

What has kept you from starting an exercise program:: Family Commitments, Injury/Illness, Other

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:: heart attack – father.

HAVE YOU HAD ANY ILLNESSES IN THE LAST 12 MONTHS? IF YES, PLEASE GIVE DETAILS: appendicitis.

DO YOU HAVE ANY ALLERGIES?:: no

DO YOU HAVE ARTHRITIS, ASTHMA OR HERNIA?:: possible hernia – issues still from surgery.

ARE YOU TAKING ANY PRESCRIBED MEDICATIONS? IF YES, PLEASE GIVE DETAILS?:: thyroxine.

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: 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