Medical Questionnaire and Release of Liability

Please fill out the following form to help me understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete. I certify that my participation in Pilates and MELT is a potentially hazardous activity. I have been informed of and understand and am aware that any exercise and/or fitness activities involve a risk of injury, and that I am voluntarily participating in these activities with understanding and appreciation of the risks involved. I hereby agree to expressly assume and accept any and all risks of injury regardless of severity. I understand that all information and services provided by Kim Reis and Kim Reis Pilates are of a general nature and are provided for educational purposes only. None of the information or services provided by Kim Reis and Kim Reis Pilates are to be taken as medical or other health advice pertaining to any specific health or medical condition that I have or may have had. The information and services provided by Kim Reis and Kim Reis Pilates are not a diagnosis, treatment plan, or recommendation for a particular course of action regarding my health and are not intended to provide specific medical advice.

Thanks for submitting!