Balanced Body Fitness & Wellness Intake Form

Balanced Body Fitness & Wellness Intake Form

Complete Intake Form Prior to your Scheduled Appointment
Full name*

First NameLast Name
Address*

Street Address

Post Office Box

CityState

Postal / Zip CodeCountry
Cell Phone Number*

Area CodePhone Number
Home Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone number*

Area CodePhone Number
Fitness and Wellness Intake :

Complete All Intake Questions and Attest to Accuracy.
Birth Date*

MonthDayYear
Gender: Male/ Female*
Height*
Weight*
Were you referred by a Medical Professional or a client? Do you have an acute injury? Do you need emergency care? How did you hear about us? Please be specific.*
Describe your activities / hobbies and type of employment. Please be specific. Your lifestyle and the type of employment play an important role in determining the most beneficial program for you.*
Do you consider yourself to have a sedentary life style?*
Are you interested in weight loss or nutritional programs?*
What Fitness and Wellness Programs interest you?*
What are your specific long term and short term goals?*
Have you received a Medical Physical in the past 12 months?*
Has your Medical Doctor recommended limiting physical activities?*
Is your Doctor currently prescribing drugs or medication for blood pressure or heart conditions? *
Have you ever had surgery? Describe injuries, pathologies and type of surgery.*
Do you have any injuries or disabilities that may limit your activities? *
Do you have bone or joint problems or pain that could be worsened by change in your physical activities?*
Do you have any Heart Conditions or High/ Low Blood Pressure?*
Do you feel any chest pain or discomfort with breathing during or after physical activities? *
Do you lose balance because of dizziness or do you ever lose consciousness? *
Do you suffer from motion sickness or inner ear issues?*
Do you know of any reason why you should limit your physical activities?*
Do you Smoke or Vape?*
Are you pregnant or postnatal?*
Do you have any joint pain, muscle pain, Arthritis or Osteoporosis ?*
Have you ever had a Hernia?*
Please Attest to the Accuracy of Intake Information*

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Balanced Body Studio Policy Agreement / Please Initial Agreement.
Balanced Body Fitness Policies

Please review and approve policies before submitting Intake Form
Medical Consent / Safety Protocol and Acknowledgment Waiver Agreement :
Balanced Body Fitness and Wellness takes all precautions to ensure the safety and well-being of the client during Massage Therapy and/or Fitness and Wellness Sessions in accordance with NYS Protocol, National Exercise Association, and Sports Trainers Association. We recommend you receive Medical Clearance for your safety.

Medical Consent:

The client states they are fit for an Exercise Program and/or Massage Therapy Treatment and has received Medical Clearance for Fitness Training and/or Massage Therapy Sessions and/or understands the risk of injury involved with increasing physical activity and/or receiving treatments without the consent of a physician and has decided to go forward with a Fitness Program and or Massage Therapy Program. The client further understands and consents assessments, program design, and/ or treatments by the Therapist/ Trainer. The Therapist/ Trainer recommends Medical Clearance by a Physician before starting Therapy and/or Fitness Sessions.

Acknowledgment Waiver :

The client is hereby requesting a Consultation and/or Services with Balanced Body Fitness and Wellness LLC, Pilates Fitness & Wellness, Balanced Body Massages, Myokinesis Therapy and Daniel Thomas for the sole purpose of potentially retaining a Therapist or Personal Fitness Trainer and for no other reason. I acknowledge that I am not an agent or employee of any local, state, or federal government authority; or if I am employed as an agent or employer of any local, state, or federal government authority that I am seeking this consultation in my individual capacity and not the capacity as government agent or employee. If consultation is on behalf of a business entity and not an individual I further represent that I am either a principle, managing agent, partner or if a partner, or if an agent, that I am authorized to execute authorization and wavier on behalf of my principle.

I acknowledge that permission for me to enter the premises or any premises related to the ownership or business of Balanced Body Fitness and Wellness LLC, and/or to receive consultation and/or services is based on the above acknowledgment, and any misrepresentation made herein in order to receive the consultation and/or services will be deemed entrapment and Trespassing with Malicious Intent, intentional infliction of emotional distress and all other applicable damages.

I waive any and all defenses I may have against me for entrapment, Trespassing with Malicious intent, Trespassing, Trespassing to Chattel, harassment, fraud in the inducement, intentional infliction of emotional distress, and any other damages incurred by Balanced Body Fitness and Wellness LLC and/or Daniel Thomas as a result of misrepresentation stated above for receiving consultation and/or services rendered to me.

I am aware that signing this document under false pretenses is a crime punishable under the laws of New York State.

I have read this document and understand its contents and sign this waiver of my own free will.

Safety Protocol and Waiver:

I read and understood Balanced Body Fitness and Wellness Safety Protocol and Policies as noted in detail on our Safety Protocol Web Page.

Your safety is our priority and we strongly recommend medical clearance from a Medical Doctor before using our services. If you feel medical clearance is unnecessary and decide to go forward with our services, you must follow our strict safety protocols. You also understand and acknowledge that though our protocols are designed to minimize exposure, there is a risk of injury.
Medical Consent, Safety Protocol and Acknowledgement Waiver Agreement *

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Personal Fitness Training and/or Corrective Movement Program Agreement :
Personal Fitness Training and/or Corrective Movement Programs Agreement : During these difficult times, Treatment Options and Personal Fitness Program Restrictions may apply. Please complete the Intake Form with detailed description of your pain or disability. A MD request is generally recommended, however if you prefer, a Nurse Practitioner can evaluate Intake Form information and forward any recommendations for Treatment Options and Personal Fitness Programing. When treatment options and/or corrective exercise is evaluated, we will schedule an appointment. When you arrive for your appointment, our Therapist and Personal Trainer will complete a Physical Assessment and discuss appropriate Treatment Options. I understand the Policies and Restrictions set forth and authorize Treatment Options and/ or Personal Fitness Program. I understand all risks involved. Our Studio follows strict Safety Protocols, as noted on our website. All clients are required to follow those safety guidelines. **
Note any concerns or questions regarding Treatment and Fitness Training options. If you don not have any concerns, please note NONE.
Electronic Signature. I understand and agree with the Safety Protocols/Policies and Authorize Treatment and/or Personal Fitness Training Programs. *

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Cancellation Policy
At Balanced Body Fitness and Wellness, all appointments are binding. All sessions are prepaid. Rescheduling requests must be received at least 24hrs before your session in order to avoid being charged. Clients who do not request a rescheduling appointment within 24hr notice will be charged 100% of the regular price of your session.
Cancellation Policy Agreement*

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
NYS PICTURE ID / DRIVERS LICENSE (required to submit with Intake Form)*

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DOWN LOAD NYS PICTURE ID/DRIVERS LICENSE or Send copy of NYS PICTURE ID/ DRIVERS LICENSE via Text to 631.318.4696 Cancelof
Date of Approval of Noted Policies:*

MonthDayYear
Date
Should be Empty:

Balanced Body Fitness & Wellness Intake Form

Fitness and Wellness Intake :

Balanced Body Fitness Policies

Medical Consent / Safety Protocol and Acknowledgment Waiver Agreement :

Personal Fitness Training and/or Corrective Movement Program Agreement :

Cancellation Policy