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TherHab Fitness Questionnaire

First Name

Last Name

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

Email Address

Date of Birth

If you answered yes to any question, please elaborate.

Please state your wellness goals and past exercise experience.

Signature

Today's Date

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY By enrolling in TherHab Fitness Classes I hereby agree to the following: Virtual fitness classes may require physical exertion, which may be strenuous. Although unlikely, a physical injury could occur. I am fully aware of the risks and hazards involved and I agree to assume any responsibility for any injury. I have consulted with a physician regarding my participation in TherHab Fitness Virtual Classes and I represent and warrant that I am physically able to participate in exercises classes and I have no medical condition that would prevent my full participation in these fitness classes By participating in any fitness exercise you are doing so at your own risk. GroupHab and TherHab Fitness will not be responsible or liable for any injury or harm you sustain as a result of our fitness videos. I have read the above release waiver of liability and fully understand its contents. I voluntarily agree to its contents. I declare that the info I have provided is accurate & complete.I understand that TherHab Fitness is required to maintain the privacy of my health information in accordance with the terms of its HIPAA Privacy Notice. I further acknowledge that I can receive a copy of the current HIPPA Privacy Notice at any time. I understand that TherHab Fitness restricts its uses and disclosures of my health information for physical therapy treatment, health care operations and participation in Live Zoom Classes. By signing this form, I consent to the Practice's use and disclosure of my health information for treatment, participation in Zoom Videos, and health care operations.

I agree to the terms & conditions

Your Signature