The Wellness Hub Client screening Form

Name*

First NameLast Name

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In Case of Emergency Contact- Name and Number*

Do you have any food intolerance's?*

YesNo

If yes, please provide details *

Do you have any allergies?*

YesNo

If yes please please provide details?*

Do you have any current injuries, movement limitations or health conditions? If yes please give details. *

Please answer the following *

	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, heart condition) and/or should only do physical activity as recommended by a doctor
Do you feel any pain in your chest on physical exertion?
In the past month have you had any chest pain when doing physical activity?
Do you ever lose balance due to dizziness or do you ever lost consciousness?
Have you ever been told by a doctor that you have a bone, joint or muscular problem that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing you medication for a heart condition or blood pressure?
Do you know of any other reason why you shouldn't do physical activity?
Are you pregnant or have given birth in the past 6 months?
Are you currently breast feeding?
Have you had any recent surgery (past 12 months)
Are you currently on any other medication?
Do you have a lung condition (ie asthma?)
Have you been diagnosed with a mental health condition?
Do you consider yourself to have low mood?/Any mental health concerns?

If you have answered YES to any of the following please give more details below*

Please detail any medication you are currently taking?

Informed Consent

Sound Bath- This does not come with any specific contraindications, however, if you have epilepsy, or any other conditions that make you sensitive to sounds, or you feel you may be uncomfortable please make us aware before the event.

I agree that I have answered all questions to the best of my knowledge, and I affirm that I am fit and can participate in physical activity. If I have answered yes to any of the above questions or have any doubts that I am fit and well enough to take part in exercise, I will first consult with my doctor to get medical clearance. I acknowledge that participation is at my own pace and comfort level, and if anything feels too challenging I should discontinue the session.

I agree to use my judgment to determine a safe exertion level, and to stop any activity that feels outside my capabilities/limitations. I will not continue with any exercise that does not feel safe for me. I understand that by signing this agreement I waive and release The Wellness Hub with Laura and Jane in any way from liabilities and demands due to injury, loss, or adverse health conditions due to participation.

I have read and understand this document and wish to participate in fitness activities.

Please be aware that the property grounds are on multiple levels, please bring suitable footwear, and also make us aware of any physical limitations. If you require assistance in navigating the property due to physical limitations, please make us aware of this in advance so we can put the correct support in place.

Please use this section to detail any 1:2:1 services you wish to book. Specifiy the practitioner, service, day and time. We will then get back to you with a schedule for 1:2:1 appointments.

I consent to there being photography taken while at this event?*

YesNo

I consent to any photography that includes me to be used for promotional materials/social media? (Please be aware we will never tag, or name you)*

YesNo

Date *

Date

Signature of Participant *

Client screening Form

Basic Info

Health and Fitness Screening