Your Name: (required)
D.O.B: (required)
Gender: (required) Male Female
Occupation (required)
Address (required)
Telephone (required)
Your Email (required)
Client Health History and Release Form
Name (required)
In case of emergency, please notify:
Phone (required)
Please note: In order to assist you in the development of a rewarding physical fitness program, we need to have your honest and accurate responses.
General Medical History & Information
Current fitness level: (select one, 5 being the best shape) (required) 1 2 3 4 5
Goals for camp: (required)
Are you under the care of a physician, chiropractor, or other health care professional for any reason? If yes, list reason: Are you aware of any disease or disorder that would complicate your participation in a testing or exercise program? Are you taking any medications? If yes please indicate the type of medication, dosage, frequency and reason(s) for taking it. Please list any allergies:
Has your doctor ever said your blood pressure was too high (required) yes no
Is there any reason not mentioned here why you should follow a modified exercise program? If so, please explain.
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort: Head / Neck: Upper Back: Shoulder / Clavicle: Arm / Elbow: Wrist / Hand: Lower Back: Hip / Pelvis: Thigh / Knee: Lower Leg / Ankle / Foot:
Are you a smoker? If so, what is your smoking frequency?
Are you, or could you be pregnant? (required) no yes
I (type name) , have voluntarily enrolled in a structured, group training program run by REP’s Registered Naomi Eunson. Naomi agrees to provide workouts and other services as described above and the participant agrees to pay in full for said services. I acknowledge that participating in BOOTCAMP F.I.T involves movement and can entail some risk of personal injury, and that it is my responsibility to ensure that I am physically and mentally fit to attend classes. I acknowledge that if I have a medical condition of any kind,that I must get a doctor’s approval before I can participate in a personal training program. I acknowledge that either I have had aphysical examination and have been given my doctor’s permission to participate or I have decided to participate in the training activities and programs without the approval of my doctor and do hereby assume all responsibility for my participation in said activities and programs. I further acknowledge that Ihave NOT been told by a doctor that I may not participate in a rigorous exercise training program due tohealth conditions. I agree to disclose any physical limitations, disabilities, ailments or impairments which may affect my ability to participate in said sport-specific training program and any changes to this document's accuracy in the future. Naomi Eunson may from time to time take photographs or short videos for the use of marketing. I consent to these been used for marketing purposes. I will respect the space of others and ensure that whatever is shared by the other participants in feedback remains confidential.
Date:
Full name:
Tick box to accept the above terms.
(By sending this form via email, you are formally agreeing to the above statement - Thank you!)
