Emergency Contact
Name:: Timothy Borg
Contact Phone Number:: 433643629
Relationship:: Friend
Why are you here?
What do you consider to be your number one priority?:: regain muscle tone and strength
Name two areas of your life which you are not happy with right now and would like to improve?:: confidence/ motivation and pain management
What has kept you from starting an exercise program:: Work, Lack of Motivation, Injury/Illness
Medical Backgrouund
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING: Low or High Blood Pressure
IS THERE A FAMILY HISTORY OF ANY OF THE ABOVE CONDITIONS? IF SO, PLEASE LIST THEM:: yes, stroke, diabetes, heart conditions, low and high bp.
HAVE YOU HAD ANY ILLNESSES IN THE LAST 12 MONTHS? IF YES, PLEASE GIVE DETAILS: no
DO YOU HAVE ANY ALLERGIES?:: yes, augmentin penicillin, cephalexin, wasps
DO YOU HAVE ARTHRITIS, ASTHMA OR HERNIA?:: no
ARE YOU TAKING ANY PRESCRIBED MEDICATIONS? IF YES, PLEASE GIVE DETAILS?:: to discuss
Are you receiving any treatment from a doctor, physiotherapist or other health professional? If Yes – What for?:: yes- physio- lower back
Have you been hospitalized recently or given birth in the last 3 months?:: no
NECK: NO
If YES, Please elaborate::
BACK: YES
If YES, Please elaborate:: l4, l5 disc herniation
SHOULDERS: NO
If YES, Please elaborate::
HIPS: NO
If YES, Please elaborate::
KNEES: YES
If YES, Please elaborate:: dislocation at age 16
ANKLES: YES
If YES, Please elaborate:: fractures over 3 years ago in right.
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