Health History | Flow and Glow Pilates & Fitness, LLC

First Name

Last Name

Email Address

Mobile Number

Date Of Birth

Secondary Number

Weight

Height

Gender

In Case Of Emergency, Contact ...

Emergency Contact Phone number

Check if you have:

High Blood Pressure >130/90

High Cholesterol >240

Smoked Cigarettes

Family History of coronary or other atherosclerotic diseases in parents or siblings prior to age 55

List any medications that you are currently taking:

Are you presently on a special diet?

Do you have any physical condition, impairment, or disability that might affect your ability to undertake an exercise program?

Any other important medical information that would be helpful in designing a safe and effective exercise program for you?

Section 3 Agreement

I am in proper physical condition to participate in the Activity, and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death.

Initial Here

I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured.

Initial Here

I also understand that (please initial);

I will notify instructor immediately of any pain and/or major discomfort felt during any activity.

Initial Here

If I am pregnant or plan to become pregnant during course of the Activity, I will notify instructor of any restrictions/limitations per physician prior to participation in a fitness class.

Initial Here

Initial Here. This constitutes a signature.

Date