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Intake & liability Release
Date of Birth
Do you have injuries, Past or Current?
Please specify recent and past injuries. When? How? What is the injury?
What is your occupation?
Check the activity level of your occupation
Please indicate if you have been diagnosed wih any of the following:
Anxiety or Panic Attacks
Dry, itchy skin, rashes
High blood Pressure
Irrititable bowel Syndrome
If you checked any of the above, please explain the condition. If your condition is not listed, please specifiy.
Please list any recent or past surgeries, especially if it will impede your ability to exercise:
What are your fitness and wellness goals? Please be specific and explain. The more we know the better we can tailor your program.
What do you currently do for your fitness and wellness? What do you like? What do you not like? Be specific as it will help us tailor your program.
If you could change 3 things about your fitness & wellbeing, what would those be? Rate them according to importance
What are your biggest challenge(s) to reaching your fitness and wellness goals?
By working together in the program, what are your expectations?
I declare that the info I’ve provided is accurate & complete
I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.
I accept terms & conditions
Thanks for submitting!
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