Waiver Name * First Name Last Name Email * Phone * Country (###) ### #### Will you be attending? * Yes No Still Unsure Do any of the following apply to you? * High blood pressure cancer arthritis Epilepsy Regular smoker Diabetes Osteoporosis/osteoarthritis Recent surgery Asthma Non of the above apply to me (or Other conditions) Please explain any checked items from above Please tick the following that apply * Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? If you have diabetes (Type I or Type II), have you had trouble controlling your blood glucose in the last 3 months? Do you have any undiagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise? None of the above apply to me. Please tick the following that apply * Yoga CrossFit/ Olympic Weightlifting / Barbell squatting / Deadlifting Regular coffee consumption (1+/day) Regular alcohol consumption (>1/week) Cycling Long distance running (5+km at a time) See a regular applied health professional (physio, chiro, massage, Osteo) Vegan/Plant based diet Regularly eat grains None of the above apply to me. How did you hear about me? * Cancellation policy I require a minimum of 24 hours notice if you wish to cancel or reschedule. Non-attendance to a booked appointment, with no reasonable explanation, will attract a 100% charge. This policy ensures my clients are able to access my services rather than being put on a waiting list or turned away. Please click "I agree" below none I agree Please give me a brief history of previous injury and treatment * Please give me a summery of your current exercise regimen, if any. * What would you consider to be a successful result for you in three to six months time? * Thank you!
