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FULL CIRCLE FITNESS RELEASE FORM

   
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Have you every participated in yoga/personal training/Pilates before?
Yoga Yes No
Personal Training Yes No
Pilates Yes No

If so, what type and how often do you practice?


What do you consider to be helpful in your training sessions in the past?


Do you have any physical injuries or chronic conditions that could potentially affect your session today?


State of Health

Check any of the following symptoms, past or preset:
Back Pain Slipped Disc
Gout Scoliosis
High Blood Pressure Hemophilia
Stroke Rheumatic Condition
Crohn's Disease Neurological Condition
Neck Pain Joint Aches
Arthrosis Bone Fractures
Varicose Veins Heart Attack/Pacemaker
Hormonal Condition Abdominal Condition
Uro-genital Condition Sizures or Epilepsy
HIV/AIDS Headaches
Arthritis Reduced Mobility
Lung Condition Thrombosis
Angina Pectoris Diabetes Mellitus
Irritable Bowel Skin Condition
Mental Illness Other Operations and/or Implants
If other, please specify: 

Give a brief history of the problem:


Please list any other conditions I should be aware of:


Women Only:
Are you pregnant? Yes No
If so, how far along in the pregnancy are you? 

Do you have any of the following today?
Sunburn Inflammation
Open Cuts or Bruising Allergic Reaction
Cold Flu

General Condition
Please indicate the type and quantity of consumption:
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How much exercise do you get per day/per week?
By clicking the submit button, I agree to the following statements. I understand that no medical diagnosis will be given and no promises of cure have been made. I understand that a treatment or Yoga practice is no replacement for competent medical care. I understand that all physical activity entered into is on a voluntary basis only. In case of injury, I take full responsibility and release Full Circle Massage from liability. I am responsible to pay for private sessions I do not attend or those I cancel within 48 hours notice.
 
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