Emergency Contact

Name::

Contact Phone Number::

Relationship::

Why are you here?

What do you consider to be your number one priority?:: Rehabilitation

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

What has kept you from starting an exercise program:: 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: Breast cancer

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?:: Breast Cancer

Have you been hospitalized recently or given birth in the last 3 months?:: Yes

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: YES

If YES, Please elaborate:: Left knee old injury

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