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In Home Yoga
In Home Pilates
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>> Get Started Now <<
About
Your Guides
Press & Testimonials
Private Sessions
In Home Personal Training
In Home Yoga
In Home Pilates
Pricing and Policies
>> Get Started Now <<
Health History & Waiver
Personal Health History
General Information
Title
Select
Dr
Miss
Mr
Mrs
Ms
Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Email
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Get Email Updates
Yes, I would like to receive email updates from Barefoot Tiger ** (don't worry, we don't like spam either!)
Cardiovascular Risk
Please check any that apply and age of onset
High Blood Pressure
You
Mother
Father
Grandparent
High Cholesterol
You
Mother
Father
Grandparent
Diabetes
You
Mother
Father
Grandparent
Heart Disease (heart attack/stroke)
You
Mother
Father
Grandparent
Do you presently smoke cigarettes?
*
Yes
No
Height
*
Current Weight
*
Goal Weight (if different):
Personal History
Total Serum Cholesterol
HDL
Blood Pressure
Has your doctor ever restricted your physical activity?
*
Yes
No
Please Explain
Do you have any allergies?
*
Yes
No
Please List
Do you ever experience chest pains or tightness?
*
Yes
No
Unusual shortness of breath or dizziness during mild physical activity?
*
Yes
No
Are you taking medication or vitamins?
*
Yes
No
Please list type and purpose
Females Only
Are you currently pregnant?
Yes
No
How far along are you?
Are you planning on becoming pregnant any time soon?
Yes
No
Injuries
Please check the following injuries you have had and specify which bone, muscle, joint, etc., and the year the injury occurred
broken bones
muscle strain / sprain
ligament / tendon / cartilage injury
joint injury or chronic pain
back injury or chronic pain
nerve entrapment
(e.g. carpal tunnel syndrome)
other
Are you currently being treated for any of the above injuries?
*
Yes
No
Please specify the type of treatment
Have you had any serious or chronic illness, operations or traumatic accidents in your lifetime? This is important to know so scar tissue, which can greatly affect your facial system and muscle function, can be addressed.
*
Yes
No
Please explain
Lifestyle
If you are currently employed, do you consider your job to be:
*
sedentary
active
Occupation
*
Hours of work per week
*
Are you
*
generally sedentary
a weekend or vacation exerciser
physically active at least 3x per week
Goals
What are your goals for the next:
1 month
6 months
1 year
On a scale of 1-10, how serious are you about accomplishing your health and fitness goals?
1
2
3
4
5
6
7
8
9
10
Do you currently have a regular exercise program?
*
Yes
No
please summarize
Training Interest
Please check activities which interest you:
*
weight training
running
outdoor workouts
walking
yoga
meditation
stretching
rock climbing
pre-natal
other
Describe
Does your significant other support you in your endeavor to be more fit?
*
Yes
No
What has stopped you from either getting started or staying on a consistent exercise and nutritional program in the past?
*
What type of cardiovascular exercise do you enjoy the most?
*
treadmill
Pre-core elliptical
cycling
swimming
other
Describe
How much time do you want to spend working out?
*
Do you have exercise equipment at home?
*
Yes
No
Kind
Do you feel that there are specific exercises that would not interest you or might cause you pain or discomfort?
*
Yes
No
Please explain
Understanding that it is difficult to spot-train, are there any specific areas of your body you would like to target with our work together?
*
Client Waiver
All checkboxes required to continue
*
I understand Barefoot Tiger has a 24 HOUR CANCELLATION POLICY. If I cancel an appointment within the 24 hour window, I understand that I will be charged for the session and the teacher / trainer will be paid as if the session occurred.
I have stated all of my known medical conditions. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions stated in my Personal Health History form.
I realize it is solely my responsibility to keep Barefoot Tiger updated on any changes in my physical health and I understand that BT shall not be liable should I fail to do so.
I understand the purpose and function of the following programs provided by Barefoot Tiger: Personal Training, Yoga, Pilates (including but not limited to)
• Weight training
• Cardiovascular exercise
• Stretching and muscle release
• Other physical activities
• Yoga
• Pilates
I understand that Barefoot Tiger does not diagnose illness, disease, or any other physical or mental disorder. BT does not prescribe medical treatment of pharmaceuticals. It has been made clear to me that the services provided by BT are not substitutes for Medical examination or diagnoses and that it is recommended that I see a medical practitioner for any physical or mental ailment that I may have.
I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injuries, abnormal blood pressure responses, and, in rare instances, heart attack or death. Every effort will be made by Barefoot Tiger to minimize these risks. If at any time I have questions concerning the content, policies, or procedures regarding the Barefoot Tiger program, I will discuss these questions with the BT office.
This agreement applies to 1) Personal injury (including death) from accidents or illness arising from the participation in physical activities including, but not limited to, classes, private sessions, workshops, retreats, observation, and individual use of facilities, premises or equipment; and to 2) any and all claims resulting from the damage to or loss of property.
In addition, I release, discharge and waive any and all responsibility of Barefoot Tiger of any of the aforementioned parties from ordinary negligence. I indemnify and hold harmless Barefoot Tiger, its officers, agents and employees.
Signature
*
Date
*
Date Format: MM slash DD slash YYYY