Emergency Contact
Name:: Helen Dennis
Contact Phone Number:: 405740894
Relationship:: Mother
Why are you here?
What do you consider to be your number one priority?:: fitness, tone
Name two areas of your life which you are not happy with right now and would like to improve?:: Inadequate amount of exercise
What has kept you from starting an exercise program:: Procrastination, Lack of Motivation
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?:: Slight exercise induced asthma
ARE YOU TAKING ANY PRESCRIBED MEDICATIONS? IF YES, PLEASE GIVE DETAILS?:: Pill
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: YES
If YES, Please elaborate:: Bad posture causes migraines
BACK: NO
If YES, Please elaborate::
SHOULDERS: YES
If YES, Please elaborate:: Bad posture causes migraines
HIPS: NO
If YES, Please elaborate::
KNEES: YES
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