Health Waiver-Perpetual Energy

First Name

Last Name

Date of Birth

Age

Email

Phone Number

Address

I declare that I am fit to part take in physical activity (yoga/Pilates/mobility/animal locomotion) and have a doctor's or specialist's clearance if necessary to participate.

Yes

No

I understand that Pilates/Yoga/Kinesiology/Dorn/Massage does not replace medical treatment where necessary.

No

I understand that muscle testing might be used as a tool to ascertain muscle function and neurological connection and relevant techniques to correct muscle imbalances can be applied to assist my body to return to muscular balance..

Yes

No

Please specify anything we should know about in relation to injuries/surgeries and musculo-skeletal pain. Please be as specific and detailed as you can. Note sides and dates:

If you are currently in pain can you rate the level it is on? Also note it is in the same place the original injury or pain was on.

Please specify anything we should know about in relation to health conditions including Osteo Arthritis, Rheumatoid Arthritis, Ostepenia or any other bone conditions. Please be as specific and detailed as you can:

Please specify anything we should know about in relation to any other health conditions i.e. blood pressure, blood sugar, diabetes 1 or 2, neurological, hormonal or heart conditions, mental-health conditions and meditations taken on a chronic basis.

Are you Pregnant or Breastfeeding? Have you given birth naturally or via C-section (note dates)?

What is your current exercise routine?

What are your health, wellbeing and fitness goals. Be specific. How will it look different from what you have now?

Any other information that you feel prevalent.

Current Diet and Water consumption

Current Medical Conditions and Medications

I agree I am fit to perform physical activity/exercise. I take responsibility for my own wellbeing in an in venue or online class. I am aware of my own limitations and injuries and take adjustments where necessary and or advised by the instructor.

I agree to work at a level suitable for my body and ability. I recognise that I or my next of kin can not hold the instructor/Perpetual Energy or venue responsible for for any injury or loss occurring during a class in venue or online.

I agree to the privacy policy and terms & conditions www.perpetualenergy.org

I agree that from time to time tasteful photographs/videos taken during sessions can be used in promotional material. These normally do not include faces unless cleared with the participants and are artful in nature.

I agree to receive emails with health and wellness information, specials, classes and other information that might be of interest for my general wellbeing.

Your Signature

*

Date

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