Medical Waiver And Release Form printable pdf download

Medical Waiver And Release Form

The Designed Body

Medical Waiver and Release Form

For

Participation in Yoga/Pilates Training

Please circle all conditions that you currently have or have had in the past year.

Hypertension

Yes

Heart Disease

Yes

Pregnancy

Yes

Skeletal injury (broken bones)

Yes

Osteoporosis

Yes

Surgery (please explain below)

Yes

Weight gain of more than 20 pounds

Yes

Weight loss of more than 20 pounds

Yes

Currently taking medication

Yes

Has a physician told you not to start an exercise program

Yes

Been in Physical Therapy

Yes

If you answered “yes” to physical therapy within the past 12 months you will be required to

obtain a physician’s release prior to beginning a training program with out studio.

Please list all medications you are currently taking

______________________________________________________________________________

Please explain recent surgical procedures

______________________________________________________________________________

By signing below you acknowledge that you are, to the best of your knowledge, free from any

disease or condition that would prevent you from participating actively in the above-mentioned

classes.

Print Name

________________________________

Signature

________________________________

Date

________________________________

Medical Waiver And Release Form