Health Form

Health Form - For Your Safety

* Indicates required field

Email *

Name *

First

Last

D.O.B (dd/mm/yy) *

Weight *

Height *

Mobile Number *

Address *

Suburb & Post Code *

Has your doctor ever told you that your blood pressure was too high? *

Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program? *

Yes No

If yes, what would not allow you to participate in a physical fitness program? *

Please initial at the bottom box that you have read and reviewed the risks associated with exercising and agreeing that you are physically able to exercise and there is no medical history that would prevent you from exercising safely. ----------------------------------- BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF CELINDA BEAUDRY. BUYER ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYER’S PARTICIPATION IN THE PHYSICAL ACTIVITES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT AR NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER-EXERTION OF A BUYER, SLIP AND FALL BY BUYER, OR AN UNKNOWN HEALTH PROBLEM OF BUYER. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY INVOLVED WITH PARTICIPATION IN THE PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYISCAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF BUYER TO SEEK COMPETENT MEDICAL OR OTHER PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED WITH THE ABILITY OF BUYER TO TAKE PART IN CELINDA BEAUDRY’S PHYSICAL ACTIVITIES. BY SIGNING THIS AGREEMENT, BUYER ASSERTS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY FOR NOT EXCEEDING HIS OR HER PHYSICAL LIMITS. *

Please specify any injuries/surgeries (including plastic surgeries and deep internal surgeries) *

Do you feel bloated throughout the day? *

Yes No

Do you crave sweets? *

Yes No

Do you feel stressed often? *

Yes No

Do you have any allergies? *

Yes No

If yes, what are you allergies? *

On a scale of 1 to 10, how determined are you to achieve your goals? *

How satisfied do you feel about your body and it's impact on your lifestyle? *

How frequent are your bowl movements? *

Do you drink AT LEAST 8 glasses of water/day? *

Yes No

What is your overall health/fitness goal? *

What is your fitness level and experience? Please specify if you are new to exercising. *

Do you ever feel weak, fatigued, or sluggish? *

Yes No

Do you eat breakfast? *

Yes No

How many meals do you eat each day? *

How much bread do you eat? *

Do you restrict yourself from eating any foods such as meat/fruit/vegetables? If yes, please briefly state why and how it affects you. *

Do you need several cups of coffee to keep you going throughout the day? *

Yes No

Are you taking supplements? If yes, please specify. *

Feel free to share any other information about diet, health, or exercise habits. The more I know about you, the more I can help you improve your overall well being, lifestyle, and fitness. *

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