Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

MEDICAL CONDITIONS: Do any of the following apply to you? *

Heart conditions / Chest pain

Cancer

High blood pressure

Arthritis

Epilepsy

Regular smoker

Diabetes

Osteoporosis

Fatigue or lethargy

Hayfever / Sinus problems

Asthma / Respiratory problems

Muscle aches and pains

Migraines / headaches

Menstrual pains

Digestive complaints

Recent surgery

High cholesterol

Pacemaker

Osteoarthritis

Thyroid issues

Pregnant

Other

None of the above

MEDICAL CONDITIONS: Please tick the following that apply *

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

If you have diabetes (Type I or Type II), have you had trouble controlling your blood glucose in the last 3 months?

Do you have any undiagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?

None of the above apply to me.

LIFESTYLE PREFERENCES: Please tick any that apply *

Yoga

CrossFit/ Olympic Weightlifting / Barbell squatting / Deadlifting

Cycling

Long distance running (5+km at a time)

See a regular allied health professional (Physio, Chiro, Massage, Osteo)

Vegan diet / Plant based diet

Eat grains regularly (wheat, barley, rye, corn etc)

Regular coffee consumption (1+/day)

Regular alcohol consumption (>1/week)

None of the above apply to me

CANCELLATION POLICY: * - I require a minimum of 24 hours notice if you wish to cancel or reschedule. Non-attendance to a booked appointment, with no reasonable explanation, will attract a 100% charge. This policy ensures other clients are able to access our services rather than being put on a waiting list or turned away. Please tick "I agree" below *

I Agree

WAIVER: Please agree that you understand to the following statement: "I understand that Sam Lightfoot is not able to provide me with medical advice with regard to my medical fitness. This information is used as a guideline to the limitations of my ability to exercise. I will not hold Sam Lightfoot liable in any way for injuries that may occur while I am training." *

I Agree

Date *

MM

DD

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