Book a free consultation

Confidentiality Note

All information provided will be kept confidential and used solely for the purpose of designing a safe and effective program for you.

    1

    Personal & Contact Details

    Tell us a little about yourself

    Helps understand daily activity levels and postural patterns

    2

    Health & Medical History

    All information is kept strictly confidential

    Heart problems or medical supervision requirements for exercise?

    Chest discomfort during activity or at rest?

    Dizziness or fainting spells?

    Bone or joint issues aggravated by exercise?

    Currently taking any prescription medications?

    Any other medical reason to avoid physical activity?

    Current or possible pregnancy?


    Describe briefly; write "None" if not applicable

    3

    Injury History & Current Problems

    Vital for safe program design and injury prevention

    Past injuries requiring medical attention or physical therapy?


    Current pain, limitations, or physical discomfort?

    1 = very relaxed  |  10 = extremely stressed


    5

    Approximate hours

    6

    Consent & Waiver

    Please read carefully before signing

    Participation Agreement & Informed Consent

    TODO — Insert your full waiver and informed consent text here. This box is scrollable, so longer legal copy is fully supported.

    Type your full legal name as your digital signature