Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever been treated by a physician for?

Arthritis

Chronic Fatigue syndrome

Diabetes

Fibromyalgia

Heart Disease

High Blood Pressure

Gastric Reflux

Glaucoma

Multiple Sclerosis

Orthopedic/Joint (shoulder, knee, spine hip) problems

Osteoporosis

Osteopenia

Peripheral Neuropathy (numbness/diminished sensation)

Parkinsons

Rheumatoid Arthritis

Other

Are you currently pregrant? (women only)

Yes

No

Do you have any Musculoskeletal or Neuromuscular issues or prior injuries?

Adhesive Capsulitis (frozen shoulder)

Carpal Tunnel Syndrome

Plantar Fasciitis

Rotator Cuff Impingement

Scoliosis

Thoracic Outlet Syndrome

other

I am honored and pleased that you trust me with your health and fitness. I will do everything I can to accommodate your schedule and make your workout as pleasant as possible. While I understand that at times there are unavoidable circumstances for late or last minute cancellations I need to make efficient use of time during the day to train those clients that want to come in. Therefore I must stress the 36-hr cancellation policy. You will be charged the full session fee.

I agree to the 36-hr Cancellation Policy