Lifestyle Questionnaire and Waiver

Name*

Date of Birth*

Age*

Telephone number*

Email Address

Has a physician ever said you have a heart condition and you should only do physical activity recommended by a physician?*

Yes
No

When you do physical activity, do you feel pain in your chest?*

Yes
No

When you were not doing physical activity, have you had chest pain in the past month?*

Yes
No

Do you ever lose consciousness or do you lose your balance because of dizziness?*

Yes
No

Do you have a joint or bone problem that may be made worse by a change in your physical activity?*

Yes
No

Is a physician currently prescribing medications for your blood pressure or heart condition?*

Yes
No

Are you pregnant?*

Yes
No

Do you have insulin dependent diabetes?*

Yes
No

Are you 69 years of age or older?*

Yes
No

Do you know of any other reason you should not exercise or increase your physical activity?*

Yes
No

If you answered Yes to any of the above questions, talk with your doctor BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answered Yes. If you honestly answered No to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. If your health changes so you then answer Yes to any of the above questions, seek guidance from a physician.

Cancellation Policy
All sessions are subject to a 24-hour cancellation policy. If the session is not cancelled 24 hours prior to the session start time, the session fee will still be incurred by the client.
1 Month = 4 weeks.
As the client, I understand and agree to comply with the 24 hour cancellation policy.

Cancellation Policy Acceptance*

I agree to the Cancellation Policy above

Block booking Terms Acceptance

I agree to the Block booking terms below

All pre-booked sessions must be used within a 12 week period from the date of purchase. Any remaining sessions after this time will be null and void.

Signature*

Date*

Print Name (in CAPITALS)*

Step 1 (of 2)

Lifestyle Questionnaire