Health Screening Form - Warm Water - The Arthritis Movement

Email*

Phone*

Date of Birth*

Age in years*

Type of arthritis

Emergency Contact's Phone Number

Medical History

As you answered Yes, please give more information on the nature of your condition and when it was first diagnosed:*

As you answered Yes, has this occurred in the last 1-3months and are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. diabetes, cardiorespiratory disorder or other)?*

As you answered Yes, are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. Diabetes or cardiorespiratory disorder)*

As you answered Yes, has this occurred in the last 1-3months and are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. diabetes, cardiorespiratory disorder or other)?*

6. Please reflect on your health during the current periods, and note any health developments (e.g., injuries, condition diagnoses) that you think may be relevant to your participation in our exercise (Note: if no major/significant issues have arisen please write No)*

7. Do you have any other conditions that may require special consideration for you to exercise? (This many include previous or current injuries/conditions -e.g. recent/current fractures, cancer diagnosis/treatment, neurological conditions, etc)*

As you answered Yes, provide more information on your selection*

As you entered Yes, please provide more detail*

10. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. For intensity guidelines download the Exercise Intensity Guide.

As you entered yes, can you provide more detail about your current wound, skin rash or scab.*

As you entered Assistance required or dependent, please provide more detail*

As you entered Yes, please provide more detail*

The Arthritis Movement Exercise Participation Waiver

READ CAREFULLY BEFORE SIGNING

In consideration for my participation in “The program” hosted by The Arthritis Movement. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS for any and all purposes SPONSOR, The Arthritis Movement and their respective officers, servants, agents, volunteers, or employees (herein collectively referred to as RELEASEES) FROM ANY AND ALL LIABILITIES, RESPONSIBILITIES, CLAIMS, DEMANDS, CAUSES OF ACTION OR INJURY, INCLUDING DEATH, that I may sustain or to any property belonging to me whether caused by the negligence of the RELEASEES or otherwise, while participating in the Program, or while in, on or upon the premises where the Program is being conducted.

Consent Date

Health Screening Form - Warm Water

Health Screening Form – Warm Water

Medical History

The Arthritis Movement Exercise Participation Waiver

Moving Lives,