Physical History Form

Willspace Training Inc. hereby advises you that individuals with any chronic disabilities or conditions may be at risk in participating in classes, and are advised against doing so. In addition, if in the opinion of Willspace Training Inc. staff, you would be at physical risk participating in classes or personal training, you will be denied access until you furnish Willspace Training Inc. with an opinion letter from your medical doctor, at your sole cost and expense, specifically addressing Willspace Training Inc.’s concerns, and stating that such concerns are unfounded. If you decline to obtain such a letter, you will not be permitted to use the classes, personal training and facilities of Willspace Training Inc.

Name *
Address *
Phone *
Emergency Contact *
Emergency Contact
Emergency Phone Number *
Emergency Phone Number
Date of Birth *
Date of Birth
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.) *
Have you ever had any surgeries? *
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? *
Are you currently taking any medication? *
Waiver and Release *
I hereby consent to engage in physical training that may include cardiovascular, resistance, stretching and other vigorous activities (the "activity" or "activities" hereafter) offered by Willspace Training Inc. My participation in these activities is voluntary. I affirm that I do not suffer from any ailment that would be adversely affected by the activities. I affirm that all the information I have given pertaining to my current health status is reliable and accurate to the best of my knowledge. I understand that it is my responsibility to monitor my own condition throughout each training session and should anything unusual occur, I shall inform Willspace Training Inc. and consult with my physician. I hereby affirm that I am aware of the potential dangers and risks associated with the activities and therefore I agree to, subject to the foregoing paragraph, abide by all rules, guidelines and instructions provided by Willspace Training Inc. I hereby release, discharge, indemnify and hold harmless Willspace Training Inc., its agents and substitutes, from any claims, demands, and causes of action arising from my participation in the activities. I am legally competent to sign this release or my parent or guardian has read and signed this release and given me permission to sign it.