IMXHistoryForm

Name
Date

MonthDayYear
Date
Address
Cell Phone
Work Phone
Home
Email
example@example.com
Occupation
Referred by
Date of Birth

MonthDayYear
Date
Height
Weight
Gender

MaleFemale
Physician's Name
1) Please describe your current fitness program.
2) Please describe any pain you are having (back, hip) and give the history of this pain including treatment.
3) Has a doctor given you a diagnosis for this injury?
4) What are your primary objectives for joining the IM=X Pilates Program?
5) What kind of a time commitment do you want to make to achieving these objectives?
6) Would you like to change your current weight?

YesNo
If yes, how much would you like to lose?
Do you now or have you had:

Heart problems, stroke, or chest painHistory of heart problems in your familyHigh blood pressurechronic illness or conditiondifficulty with physical exercisesurgical historyArthritisbursitistendonitispregnancyhistory of breathing or lung problemsdiabetesthyroid conditioncigarette smokingalcohol consumptionincreased blood cholesterolany vitamin and mineral supplements?poor postureexcess fatigue or stress
Liability Release Waiver
I, blanks , voluntarily consent to engage in a fitness program with The IM=X Pilates Studio. I understand that in rare instances
physical exercise causes dizziness, chest discomfort, nausea, joint or muscle soreness. I agree to assume all risks involved and hereby release all employees/staff from any and all health claims, suits, losses, or causes of action for damages, injury or death, including claims for negligence, arising out of or related to my participation in a fitness program or assessments. I have read the foregoing carefully, and I understand its content. Any questions that may have occurred to me concerning this informed consent have been answered to my satisfactions.
Name

First NameLast Name
Signature

Clear
COVID-19 Release Waiver
I, blanks , voluntarily choose to assume all of the foregoing risks and accept sole responsibility for any injury, illness, permanent disability, or death related to COVID-19 arising from or in connection with my presence at IM=X Pilates NYC/ Manhattan Spine Rehab/ Pure Balance Center NYC. I hereby release and hold harmless the Facility, their employees, agents, directors, officers and representatives and other participants from and against all liabilities (statutory or otherwise) for claims, suits, demands, judgments, costs, interest and expense (including but not limited to attorney's fees and disbursements) for injury, illness, permanent disability, or death related to COVID-19 arising from or in connection with mine or my child(ren)'s presence at the Facility, even if arising from the negligence, acts or omissions of the released parties.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Liability Release Waiver

COVID-19 Release Waiver