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Your Waiver / Intake Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Emergency Contact's Name & Number

What is your current occupation?

Do you experience symptoms like? (tick all that apply)

Pain in chest, neck, jaw, upper limb or upper back when exercising

Abnormal shortness of breath at rest / during mild exertion / when lying flat

Dizziness, fainting or blackouts during / after exercise

Swollen ankles

Abnormal heart beats or palpitations

Long standing leg / calf pain when exercising that is relieved by rest

None of the above

Please list all of your medical conditions & preferences

Are you pregnant? If yes, how many weeks?

Do you have any physical injury that may prevent or limit you from exercising?

Yes

No

Have you been told by a doctor not to exercise in the last 6 months?

Yes

No

Do you know of any reason why you should not do any physical activity?

Yes

No

Do you have any injuries or pain? If yes, please explain.

Have you been in hospital and/or had surgery in the last 12 months? If yes, please explain.

Why do you want to work with Bodhi Health?

Do you think there is anything else, that may affect your sessions, that Bodhi should be aware of?

I understand that all exercise carries a risk and I voluntarily participate in Bodhi sessions with full knowledge that there is risk of personal injury, property loss or death. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Bodhi or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

I have completed the information form truthfully.

If there are any changes to my health, I become pregnant or develop any medical condition*, I will inform Bodhi immediately.

I understand that information exchanged with Bodhi is confidential and will not be released without my prior written consent, except as required by law.

I will stop doing an exercise if the teacher (or I) thinks I need to, or follow the alternatives the teacher gives me.

I am aware of, and accept, Bodhi's payment and cancellation policies.

I agree to the terms and conditions as documented on the bodhi health website (found in the footer)

Your Waiver / Intake Form

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