Name *

First Name

Last Name

Pain Characteristics

Intermittent

Constant

Dull

Sharp

Ache

Twinge

Burning

Throbbing

Tingling

Numbness

Tight

Travels/Radiates

Consent Form *

I hereby consent voluntarily to movement and/or fitness testing, and participation in an exercise and/or nutrition program administered by Integrative Fitness, LLC. I understand that both testing and program participation may include manual therapy, flexibility exercise, cardiovascular exercise, strength training exercise, body composition assessment and food consumption. The purpose of any testing will be to assess my movement ability and level of fitness so that my exercise and/or nutrition program can be safely designed and/or modified as my body changes. The purpose of exercise participation will be to improve my movement, cardiovascular fitness, muscular strength/endurance, flexibility, physical resilience and functional fitness for daily activities and/or recreational pursuits. I understand that movement and fitness testing, and participation in an exercise and/or nutrition program may involve some risks, which include abnormal heart rate, abnormal blood pressure, dizziness, fainting, and in rare instances, heart attack, stroke, and death. There may also be some risk of injury to joints, muscles, tendons, ligaments, and nerves. Every effort will be made to minimize these risks by evaluation of my medical history and current physical activity level, careful observation during all testing procedures, and appropriate movement, exercise and nutrition program design and progression. Integrative Fitness, LLC staff are trained to deal with emergency situations if they should arise. I understand the health information I have reported on my medical history and my disclosure of previous experiences with abnormal symptoms, such as shortness of breath at rest or mild activity and chest pain with exertion, may affect the safety of fitness testing and exercise program participation. I further understand that I am responsible for fully disclosing to the Integrative Fitness, LLC staff my medical history, any changes that may occur to that history, and any abnormal symptoms I experience during participation in Integrative Fitness, LLC programs. I am also responsible for reporting medications currently taken on a regular basis and any changes to those medications. I understand that the information obtained in my medical history and through testing is confidential and will not be released to anyone without my written consent. I understand that Integrative Fitness, LLC staff will be instructing me about movement and providing hands on bodywork, and that professional and appropriate physical contact may be necessary to instruct me in proper exercise form and technique. I understand that I can withdraw my consent at any time for fitness testing and exercise program participation without prejudice or penalty to me. I have read this form and understand the benefits and risks of fitness testing and exercise participation. I have had the opportunity to have any questions answered to my satisfaction. I thereby consent to participation in the fitness testing and exercise program administered by Integrative Fitness, LLC staff.

Yes

No