Health Status & Consent

Please fill out the following form prior to your first visit to the Studio or when your Health status has changed to help us understand your physical condition.

Full Name

Date of Birth

Email Address

Mobile

Reason for Visit

Do you have any current medical conditions, injuries, infectious disease or allergies? (including but not limited to: heart condition, diabetes, inflammation, skin condition, varicose veins, spinal condition, fracture, swelling)

Yes

Do you take any medications or supplements? (including but not limited to: blood thinners, beta blockers, pain relief)

Yes

If you answered yes to any question, please elaborate

*I declare that all the answers and statements contained in this personal record are true and complete. I understand that my RMT/Personal Trainer/Pilates Instructor/Yoga Teacher must be aware of all past and present conditions as this activity/treatment may affect them and I agree to update this record as necessary. *I understand that my RMT/Personal Trainer/Pilates Instructor/Yoga Teacher may offer me adjustments verbally and physically through my movement practice and I consent to this. *By undertaking a class or training I acknowledge that I do so at my own risk. My RMT/Personal Trainer/Pilates Instructor/Yoga Teacher will not be liable for any personal injury, loss or liability as a result of my undertaking of any such exercise program/treatment or following advice contained on the website or onsite.

I am over 18 years of age or the parent/guardian of the person stated above.

Thanks for submitting, we'll see you at your appointment!

Barefoot Bodywork
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Health Status & Consent

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