Health Waiver
Please take a minute to fill in the following info
First Name
Last Name
Email
Date of Birth
Have you ever suffered from
heart problems?
chest pain?
spells of dizziness or feel faint?
high or low blood pressure? or high or low cholesterol?
asthma, bronchitis, or other chest ailments?
back pain, or any other orthopaedic problem?
headaches or migraines?
None of the above
Are you currently taking any medication or any other illness that we should be aware of
If you answered yes to any of the above, please specify in further detail
Are you pregnant? If yes, how many months?
I understand that participation in any exercise program while pregnant, or immediately following, may increase the risk of injury to myself, and if applicable, to my unborn child. I confirm that I have consulted with my doctor and understand the risk
Do you have any of the following problem areas?
Neck
Shoulder
Upper Back
Mid Back
Lower Back
SI Joint
Pelvis/Hips
Sciatica
Knees
Ankles
Feet/Toes
Arms/Elbows
Wrists/Hands
None of the Above
If answered yes to any above, please specify
Your Signature
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