* Mobile Number
Home | Office Phone Number
* Home | Office Phone Number
Date of Birth
* Date of Birth
Primary Care Physician Name
Primary Care Physician Phone Number
Medical History Disclosure
What is your current occupation?
What sports, recreational activities or workout routines do you currently participate in? (Golf, Skiing, Running, Weight-Lifting, etc.) Please list all.
What are your hobbies? (reading, gardening, working on cars, exploring the Internet, etc.) Please explain.
If you've ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.), please provide details. If these conditions do not exist, please enter NONE in the field below.Text Area 3
If you've ever had surgery, please provide details. If you've never had surgery, please enter NONE in the field below
If a medical doctor has ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes, please provide details. If these conditions do not exist, please enter NONE in the field below.
If you currently taking any medication, please list all of them. If you are not taking medications, enter NONE in the field below.
Physical Activity Readiness If you answer “Yes” to one or more of the questions below, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
How did you find Oliveyah Fitness?Select
Referral from friend
Terms and Conditions
1. I have been informed of the possible injuries and potential risk to life that may result from engaging in classes. I have indicated to Oliveyah Fitness that I am is in good health, physically able to undertake the rigors of this program and have no existing medical conditions or illnesses. 2. I, on behalf of myself, my heirs, executors, administrators, assigns, and successors hereby release and hold harmless Oliveyah Fitness, coaches, employees, and if applicable, leasers of the premises, with respect to any and all injury, disability, death, or loss of damage to person or property whether caused by the negligence of the releasees or otherwise from any act or acts, whether known or unknown, foreseen or unforeseen, as a result of participation in classes by Oliveyah Fitness. 3. I furthermore agree that Section 1542 of the California Civil Code shall have no effect. I hereby waive all rights under that Civil Code Section, California Civil Code Section 1542 states as follows: 1542 (Certain claims not affected by general release.) "A general release does extend to claims which the creditor does not know or suspect to exist in his/her favor at the time of executing the release, which if known by him/her must have materially affected his/her settlement with debtor." By clicking the "I agree to all Terms and Conditions" button, you, or acting as a guardian (if under the age of 18 years old), confirm that you understand each and every clause of this Agreement. And you furthermore confirm that this Agreement was freely and voluntarily executed and that no inducements, promises, representations, or other statements were made by anyone upon which you relied in agreeing to these terms and conditions of this Agreement.
I agree to all Terms and Conditions