Barefoot Tiger | Health History & Waiver

General Information

Title

Name*

First Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Email*

Date of Birth*

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?

Do you currently have a regular exercise program?*

Yes
No

please summarize

Training Interest

Please check activities which interest you:*

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?*

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*

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Health History & Waiver