Fill and Sign the Enrollment Form Fitness Instructor Insurance

Application, Medical Questionnaire, Release, Waiver of Liability and Indemnity Agreement with _____________ (Name of Fitness Instructor) to Study Yoga and/or Cardio Kickboxing Full Name ______________________________________________________ Date of Birth _____________ Street Address _______________________________________________ City __________________________________________________ State____________ Zip______________________ Home Phone #__________________________ Cell Phone #__________________________ Email _____________________________________________ I understand that it is my responsibility to consult with a physician prior to and regarding my participating in the Yoga and/or Cardio Kickboxing Classes, Health Programs or Workshops with ________________ (Name of Fitness Instructor), and to receive prior approval to participate. I represent and warrant that I am physically fit and I have no medical condition or injury, which would prevent my full participation in the Yoga and/or Cardio Kickboxing Classes, Health Program and Workshops of _______________ (Name of Fitness Instructor)..Personal Health History Have you had any of the following? Respond with a “Y” if yes or a “N” if no in the space indicated. Please answer all questions. Do you have any allergies? [ ] YES [ ] NO If yes, please specify: __________________________________________________________ __________________________________________________________ Medications: Are you receiving allergy medication [ ] YES [ ] NO If yes, please specify: ________________________________________________________ ________________________________________________________
Drugs: what medications have you been taking and/or have you taken any other medications in the past month? if yes, explain the medication, where you take it, how often, duration, and how well does it work? have you ever had: [ ] broken skin/surgeries/surgical procedures [ ] allergic reactions/fungal infections (for example: ear infections) [ ] heart/lung problems/diseases [ ] stroke/diarrhea/bloating [ ] arthritis [ ] diabetes [ ] hypertension [ ] depression [ ] other medical problems? if yes, describe how these medical conditions have affected you: please be specific with any medical condition if you have been diagnosed with: [ ] any medical condition [ ] arthritis [ ] diabetes [ ] hypertension [ ] depression [ ] other medical problems [ ] allergies/allergies/cough [ ] thyroid/hyperthyroid [ ] any of these: heart issues brain, brain fog, trouble sleeping/sleepiness/insomnia, dizziness/Gastroparesis/fatigue, trouble concentrating/poor concentration, loss of eyesight, vision changes, hearing problems, pain/aches, nausea, pain or other discomfort, sleep problems/insomnia/insomnia, any other symptoms that aren't described above: (if any) please provide a brief description of these symptoms. Have you ever taken: [ ] any prescription drug [ ] any other medication [ ] recreational drugs [ ] herbal medications [ ] recreational drugs or herbal products [ ] non prescriptions drugs [ ] prescription or non-prescription medication [ ] natural/ergent herbs [ ] supplements/herbs? [ ] vitamins/nutrients? [ ] vitamins/fatigue/energy /weight gain [ ] blood pressure /restriction? [ ] diabetes [ ] migraines [ ] eczema/chronic wounds, sunburn (if this was not an allergy, add with "yes"). What type of medical procedures/symptoms have you had recently? have you been using or having recent medical procedures/symptoms (, skin burns, infections, burns, inflammation). [ ] diabetes: if yes, describe exactly what type and frequency. Have you had any of the following since the last question? have you any medications/dietary supplements in the following medications? [ ] birth control pills [ ] steroids, di