New Client Waiver

Full Name *

First Name Last Name

E-mail

example@example.com

Age

Has your Doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes No

Do you feel pain in you chest when you perform physical activity?

Yes No

In the past month, have you had chest pain when you were not performing any physical activity?

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes No

is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

DO YOU KNOW OF ANY OTHER REASON WHY YOU SHOULD NOT ENGAGE IN PHYSICAL ACTIVITY?

If you answer yes to any of the following questions, please explain your answer in the box provided. If no, leave blank.

What is your current occupation

DOES YOUR CURRENT OCCUPATION REQUIRE EXTENDED PERIODS OF SITTING?

DOES YOUR CURRENT OCCUPATION REQUIRE REPETITIVE MOVEMENTS?

DOES YOUR CURRENT OCCUPATION REQUIRE YOU TO WEAR SHOES WITH A HEEL (DRESS SHOES)

DOES YOUR OCCUPATION cause you mental stress?

do you partake in any recreational physical activities?

do you have any additional hobbies (reading, video games, etc.)?

Have you ever had any injuries or chronic pain?

Have you ever had any surgeries?

has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?

Are you currently taking any medication?

I,   First Name   Last Name   , have volunteered to participate in a program of physical exercise under the direction of Dale Dymkoski, which will include, but may not be limited to, weight and/or resistance training. In consideration of Dale Dymkoski’s agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Dale Dymkoski from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this exercise program, including any injuries resulting from them.

I,   First Name   Last Name   , recognize that exercise might be difficult and strenuous and there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise do exist. These changes include abnormal blood pressure, fainting, disorders in heartbeat, heart attack, and in rare instances: death.

I recognize that an examination by a physician should be obtained prior to involvement in an exercise program. If I,   First Name   Last Name   , have chosen not to obtain a physician’s permission prior to beginning this exercise program with Dale Dymkoski, I do so at my own risk.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHTS I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST DALE DYMKOSKI.

First Name   Last Name

Signature

Clear

Date

New client waiver

general and medical history

waiver, release, and assumption of risk