Retreat Medical Form

Please complete the following questions to the best of your ability. If you have any questions or concerns, please contact Nannette.

Name

First Name

Last Name

Current Fitness Levels

Select One:

I would rate my fitness level as a Beginner (has worked out 10 times or less in the last 12 months with resistance/cardio training).

I would rate my fitness level as Intermediate (works out 2-3 times per week with resistance/cardio training).

I would rate my fitness level as Advanced (works out 3-5 times per week with resistance/cardio training).

Do you have back pain?

Do you have knee pain?

Do you have other physical conditions that cause pain?

Describe

Have you had any sprains or broken bones within the last year?

Describe

Have you ever had a neck injury?

Describe

Have you ever had any surgical procedures?

Describe

Do you have asthma?

Do you have high blood pressure?

List Medications

Do you have or have had any of the following diseases?

Are you allergic to any medication?

Do you take any prescribed medications?

Do you have a seizure disorder?

How did you hear about The Wellness Coach Boot Camp/Retreats?

What are your fitness goals for the next month/The Retreat?

What are your goals for the next three months?

Are you training for a specific fitness event?

What Event?

We recommend seeking your doctor's advice before starting any exercise program,

By signing this document, I acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. I fully understand that the program may be strenuous and choose to participate completely voluntarily. I accept all responsibility for my health and resultant injury or mishap that may affect my well-being or health in any way. I hold harmless of any responsibility the instructor, facility or any persons involved with this program or testing procedures. I understand that I am responsible for my attendance and that there are no refunds for missed days. Should there be circumstances beyond my control, I am able to, at the discretion of the coach, receive credit for the unused portion of camp to use on future Boot Camp days. Camp credit is subject to approval and availability in future camp.

Date

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