top of page
HOME
MINI RETREAT
Our Store
OUR TEAM
ABOUT
SIGN ME UP
SERVICES
BLOG
CONTACT
More
Use tab to navigate through the menu items.
0
Log In
Intake & liability Release
First name
Last name
Email
Phone
Date of Birth
Address
Do you have injuries, Past or Current?
No
Yes
Please specify recent and past injuries. When? How? What is the injury?
Emergency Contact
Phone
What is your occupation?
Check the activity level of your occupation
Sedentary
Active
Physically Demanding
Please indicate if you have been diagnosed wih any of the following:
Allergies
Anemia
Anxiety or Panic Attacks
Arthritis
Asthma
Autoimmune Condition
Bronchitis
.
Cancer
Chonic Fatigue
Crohns Disease
Depression
Diabetes
Dry, itchy skin, rashes
Eczema
.
Emphysema
Epilepsy, seizures
Eye Disease
Fibromyalgia
Fungal Infection
Gallbladder Disease
Gout
.
Heart Attack
Heartburn
Heart Disease
Hepatitis
High cholesterol
High blood Pressure
Hypoglycemia
.
Irrititable bowel Syndrome
Kidney disease
Lung disease
Liver disease
Osteoporosis
Sleep apnea
PMS
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?
Initials
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
Submit
Thanks for submitting!
bottom of page