Health History Form
Just Breathing, LLC
Full Name
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First Name
Last Name
Contact Number
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Format: (000) 000-0000.
Email Address
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example@example.com
What thing(s) are you wanting to be able to do with your body, and what is your biggest limitation?
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In 2-3 months from now, how will you know if the exercise program was successful?
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Check the conditions that apply to you:
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Diabetes
Incontinence when coughing, laughing, blowing nose, etc.
Hypertension/High Blood Pressure
Arthritis
Low Blood Pressure
Currently Pregnant
Personal or family history of hernias
Personal history of osteoporosis or osteopenia
Hypermobility (double-jointed)
Family history of osteoporosis or osteopenia
History of Diastasis Recti
Pelvic floor dysfunction or disorder
Incontinence with jumping or running
History of frequent ankle sprains
Other
None
Please provide additional details regarding any of the above conditions that would be helpful for me to know:
Have you given birth?
Yes
No
Type of birth delivery:
Cesarean delivery
Vaginal delivery
Both
Are you currently taking any medication that could influence you while performing exercises?
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Yes
No
If yes, please list the medication and reason for taking:
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Please list any injuries (and dates of injuries) you have experienced:
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Please list the date and type of any operations and/or medically relevant procedures you have had:
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On a scale of 1-10, how would you rate your current health and wellness? (1=low, 10=high)
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Please Select
1
2
3
4
5
6
7
8
9
10
What is your present occupation?
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How would you describe your occupation?
Sedentary
Physically demanding
Have you ever worked with a personal trainer, physical therapist, or chiropractor before?
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Yes
No
Please share what has been helpful, AND what has not been helpful.
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Please describe any exercise program you may currently be engaged in, as well as any daily physical activity you participate in:
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On a scale of 1-10, how committed are you to making a change to improve your physical condition?
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Please Select
1
2
3
4
5
6
7
8
9
10
Knowing that performing the recommended exercises will likely need to be performed 3-7 days a week to see positive results, how committed are you to following the exercise guidelines to see improvements?
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Very commited
Somewhat commited
Unsure
Not very commited
Which do you prefer?
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An explanation of how to do the recommended exercise(s) and the "why" behind the exercise (i.e. details regarding how the muscles are working so you will understand how the exercise will positively effect your body).
An explanation of how to do the recommended exercise(s) only. You will do the exercise regardless of the reasons how it is helping positively effect your body.
Which is your predominant form of learning?
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Visual - learns best via live demonstration, photos, or videos
Auditory - learns best via listening and speaking
Kinesthetic - learns best through physical activity and hands-on experience and adjustments
Knowing that the recommended exercises are detailed and require your attention and concentration to ensure the proper muscles are being utilized during exercises, which do you prefer?
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Written instructions
Videos of the exercises
Both of the above
When it comes to assessments and adjustments, which do you prefer?
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Hands-ON assessments and adjustments
Hands-OFF assessments and adjustments
Do you understand that you are responsible for listening to your body and that you may discontinue an exercise and ask questions at any time?
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Yes
No
Is there anything else you would like me to know before we begin working together?
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ASSUMPTION OF RISK: I agree that if I engage in any physical exercise or activity, or use any equipment or facility for any purpose, I do so at my own risk and assume the risk of any and all injury and/or damage I may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using equipment and facilities, whether provided by Just Breathing, LLC or otherwise, including injuries or damages arising out of the negligence of Just Breathing, LLC or any affiliates, employees, agents, representatives, successors, and assigns. RELEASE OF LIABILITY: In consideration of being allowed to participate in the training activities and programs of Just Breathing, LLC and to use its equipment, facility and services, I do hereby forever waive, release and discharge Just Breathing, LLC and its officers, agents, employees, representatives, executors and all others acting on their behalf from any and all claims or liabilities for injuries or damages to my person and/or property, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf, arising out of or connected with my participation in any activities, programs or services of Just Breathing LLC or the use of any equipment at various sites, including home, provided by and/or recommended by Just Breathing, LLC. I have been informed of, understand, and am aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also have been informed of, understand, and am aware that physical activities involve a risk of injury, including a remote risk of death or serious disability, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in these activities or use of equipment or machinery. I also acknowledge that it is recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of exercise equipment. I acknowledge that either I have had a physical examination and have been given my physician’s permission to participate or I have decided to participate in the exercise activities, programs and use of equipment without the approval of my physician and do hereby assume all responsibility for my participation in said activities, programs and use of equipment. I understand that Kristina Walker with Just Breathing, LLC is not a physical therapist and is not practicing medicine, as well as is unable to provide any diagnoses. I also understand that any information provided is not a substitute for medical advice and it is my responsibility to seek out a medical professional. ACKNOWLEDGEMENT:I acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability, and assumption of risk. I am aware and agree that by executing this waiver and release, I am giving up my right to bring a legal action or assert a claim against Just Breathing, LLC for negligence, or for any defective product used while receiving physical activity instruction from Just Breathing, LLC. I have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.
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Yes, I agree to assumption of risk, release of liability, acknowledgement of consent terms
No, I do not agree to the above terms
INFORMED CONSENT: I desire to participate voluntarily in a progressive movement program and/or physical test in an effort to assess and improve my physical well-being. I understand that these movement activities and/ or physical tests are designed to gradually increase the workload on my circulatory systems as well as my musculoskeletal system in an effort to improve their function. The reaction of the system(s) to such activities cannot be predicted with complete accuracy. I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body. I have been informed that during my participation in a movement training program, I will be asked to complete physical activities unless symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences appear. I understand that it is my obligation to promptly inform the trainer of any signs and/or symptoms indicating abnormalities or distress, should any develop. I understand that I may decide to discontinue exercise at any time, as well as the trainer may reduce or stop my exercise program inconsideration of my safety or benefit. I understand that this program may or may not benefit my physical fitness or general health. However, possible benefits obtained from the exercise program may include improved muscular and skeletal systems, decreased aches and pains, and an increased quality of life. I also understand that during the performance of my movement training program that physical touching and positioning of my body may be necessary to ensure that I am using proper technique and body alignment. I expressly consent to the physical contact for the stated reasons above. I know that if there are any questions about the procedures or methods used during a movement session or test, I should ask my trainer. If I have any doubts, concerns or questions I should ask for further explanation. I have read this form and voluntarily consent to participate in this exercise program and/or test and realize that I am free to withdraw at any time.
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Yes, I agree to the informed consent terms above
No, I do not agree to the above terms
Signature
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