Medical Waiver Form Name * First Name Last Name Email * Do any of the following apply to you? * high blood pressure cancer Arthritis Epilepsy Regular smoker Diabetes Osteoporosis Asthma Recent surgery High cholesterol Pacemaker Osteoarthritis Thyroid issues Pregnant None of the above apply to me. Please explain any checked items from above 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? Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? 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. How did you hear about us? * CANCELLATION POLICY: * - We require a minimum of 24 hours notice if you wish to cancel or reschedule. Non-attendance to a booked appointment 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 click "I agree" below * I Agree None Attending group classes and private sessions By signing this form you consent to be in photo and video content created by Functional Patterns Sydney used for social media promotion. What would you consider to be a successful result for you in three to six months time? * Thank you!
