Services
Results
Posture Results
Testimonials
About
What Is Functional Patterns
Training Methodology
Bio & Qualifications
Prices
Contact
Home
Medical Waiver
Book Now
Services
Results
Posture Results
Testimonials
About
What Is Functional Patterns
Training Methodology
Bio & Qualifications
Prices
Contact
Home
Medical Waiver
Book Now
Waiver & Questionnaire
Medical Waiver & Questionnaire Form
Please complete the form below
Name
*
First Name
Last Name
Date of birth
*
MM
DD
YYYY
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
*
Subject
Message
MEDICAL CONDITIONS: Do any of the following apply to you?
*
Heart conditions / Chest pain
Cancer
High blood pressure
Arthritis
Epilepsy
Regular smoker
Diabetes
Osteoporosis
Fatigue or lethargy
Hayfever / Sinus problems
Asthma / Respiratory problems
Muscle aches and pains
Migraines / headaches
Menstrual pains
Digestive complaints
Recent surgery
High cholesterol
Pacemaker
Osteoarthritis
Thyroid issues
Pregnant
Other
None of the above
Please explain any checked items from above
*
MEDICAL CONDITIONS: Please tick the following that apply
*
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
If you have diabetes (Type I or Type II), have you had trouble controlling your blood glucose in the last 3 months?
Do you have any undiagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?
None of the above apply to me.
Please explain any checked items from above
*
LIFESTYLE PREFERENCES: Please tick any that apply
*
Yoga
CrossFit/ Olympic Weightlifting / Barbell squatting / Deadlifting
Cycling
Long distance running (5+km at a time)
See a regular allied health professional (Physio, Chiro, Massage, Osteo)
Vegan diet / Plant based diet
Eat grains regularly (wheat, barley, rye, corn etc)
Regular coffee consumption (1+/day)
Regular alcohol consumption (>1/week)
None of the above apply to me
INJURIES: Describe your history of injuries, breaks and/or surgeries in chronological order. (Create a new line for each answer)
*
PAIN: Are you currently in any pain? Please describe the chronology of your pain issue(s). (Create a new line for each issue)
*
SPORTS: List the sports you have played in chronological order. Note the length of time played for each. (Create a new line for each sport.)
*
TRAINING: List the types of gym or personal training systems you have done in chronological order (e.g. weights / HIT / Circuit / Pump / Cardio etc). Note the length of time for each. (Create a new line for each answer.)
*
PRACTITIONER HISTORY: Please list the types of practitioners you have consulted in the past to resolve your physical issues – and how they have/have not helped. (Create a new line for each answer.)
*
How did you hear about me?
*
RESULTS: List three goals you would like to achieve in 3 - 6 months and on a scale of 1 - 10, how important is it to achieve that result?
*
CANCELLATION POLICY: * - I require a minimum of 24 hours notice if you wish to cancel or reschedule. Non-attendance to a booked appointment, with no reasonable explanation, will attract a 100% charge. This policy ensures other clients are able to access our services rather than being put on a waiting list or turned away. Please tick "I agree" below
*
I Agree
MEDIA CONSENT: - By signing this form you consent to be in photo and video content created by me used for social media promotion. (I will always consult you before publishing any content and discuss the option to anonymise your identity)
WAIVER: Please agree that you understand to the following statement: "I understand that Sam Lightfoot is not able to provide me with medical advice with regard to my medical fitness. This information is used as a guideline to the limitations of my ability to exercise. I will not hold Sam Lightfoot liable in any way for injuries that may occur while I am training."
*
I Agree
Date
*
MM
DD
YYYY
Thank you! Your form has been submitted and I’ll get back to you shortly
