The Spa At Yellow Creek Guest Physical Readiness & Liability Form

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The Spa at Yellow Creek Guest Physical Readiness & Liability Form
Date: ______________________
First Name: ______________________
Last Name: ______________________________
Address: ___________________________________________ Zipcode: _______________
Home Phone: ____________________ Cell Phone: _______________________________
Email: _________________________________@____________________________________
Areas of Interest (check):
Gym Membership
Personal Training
Group Exercise
Spa Services
Please read the following questions carefully & answer them honestly. All
information is kept confidential:
Check One
Yes
No
1. Has a doctor ever said you have heart trouble?
Yes
No
2. Do you frequently suffer from pains in your chest?
Yes
No
3. Do you often feel faint or have spells of severe dizziness?
Yes
No
4. Has a doctor ever told you that you have joint or bone
problems that has been aggravated by or may worsen with
exercise?
Yes
No
5. Do you have any medical conditions?
Yes
No
6. Is there any other reason not mentioned as to why you
should not engage in physical activity on a regular basis?
Please explain below.
______________________________________________________________________________
VOLUNTARY ASSUMPTION OF RISK:
I understand that any exercise, personal training & lifestyle program involves the risk of injury,
despite reasonable precaution & without anyone being at fault. I know that people can & do
become injured while doing aerobic exercise or while working with weights & other fitness
equipment. Injuries that can occur include but are not limited to dizziness, fainting, nausea,
muscle cramping, muscular-skeletal injury, broken bones, sprains & strains. In rare instances,
people may experience a heart attack, stroke or sudden death. I understand that there are risks
associated with weight loss or eating certain foods. Risks can include (but are not limited to) an

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