Pilates, Yoga & Barre Wellness Studio
815 St. Joseph Street (lower level) Rapid City, South Dakota
WELLNESS ASSESSMENT QUESTIONNAIRE
Name:_____________________________ How did you hear about us?:____________If referred, by who?__________________
Address:_________________________________________ City: _____________________ State:__________ Zip: __________
Date of birth:______________Age:___________ Height:_____________ Weight:___________ Ideal or goal Weight:_________
Name of contact in case of emergency:_____________________Relationship:___________Cell #:________________________
1. Are you currently or have you been a member of a wellness studio or facility before? Yes______________ No___________
2. Do you have experience with Pilates, Yoga or Barre? Yes__________No_________
*If so, please explain:______________________________________________________________________________________
3. Have you been exercising regularly for the past 6 months?_______If yes, what type of exercise?________________________
4. What type of exercise do you enjoy most?___________________________________________________________________
5. Please list any habits you would like to change: _____________________________________________________________________________________________________
6. Please list any wellness goals you wish to achieve:
________________________________________________________________________________________________________
7. In your opinion, what factors have slowed your progress in the past? (Circle all that apply):
Time Money No facility Procrastination Lack of support
Discipline Knowledge Experience Accountability Lack of expertise
8. I would like to: (circle all that apply):
Lose inches/weight Gain inches/weight Maintain Look better Live healthier Find Balance
9. On a scale of 1 – 10, how serious are you about achieving your wellness goals & committing to a healthy lifestyle?
1 2 3 4 5 6 7 8 9 10
10. Is there anything we should be aware of? (i.e past injuries, surgeries, current issues, etc?) If so, please explain:
________________________________________________________________________________________________________
RELEASE AND WAIVER OF LIABILITY/ACKNOWLEDGEMENT OF ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF CORE CONNECTIONS.
Member acknowledges that the Personal Training/Fitness Assessment hereunder could include participation in strenuous physical activities, including but not limited to, aerobic, weight training, and various aerobic conditioning and body weight training. Member acknowledges these Physical Activities involve inherent risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and other illness, soreness, or injury however caused, occurring during or after the Members participation in the Physical Activities. Member further acknowledges that such risks include but are not limited to, injuries caused by the negligence of an instructor or other person, defective or improperly used equipment, over exertion of a Member, slip and fall by Member,or an unknown health problem of Member. Member agrees to assume all risk and responsibility involved with participation in the Physical Activities.
Member affirms that Member is in good physical condition and does not suffer from any disability that would prevent or limit participation in the Physical Activities. Member acknowledges that participation will be physically and mentally challenging, and Member agrees that it is the responsibility of Member to seek competent medical or other professional advice regarding any concerns involved with the ability of Member to take part in the Physical Activities. Member, on behalf of Member, his or her heirs, assigns the next of kin, agrees to fully release CORE CONNECTIONS (as well as any of its owners, instructors, related entities, employees or other authorized agents, including Independent Contractors) from any and all liability, claims and/or litigation actions that Member may have for injuries, disability or death or
other damages of any kind, including but not limited to punitive damages, arising out of participation in the Physical activities, including but not limited to the Personal Training/Nutritional Program and the Physical Activities, even if caused by the negligence, intentional acts or omissions and/or any other type of fault of CORE CONNECTIONS, it’s owner’s, employees or other authorized agents including Independent Contractors.
I give permission for Core Connections to use photo’s, video or audio recordings. I understand that photos/recordings taken may be published on the Core Connections website, Facebook, Youtube, Idea Fit or other media sites.
By signing this Agreement, I assert that I am capable of participating in the physical activities offered.
I agree to assume all risk and responsibility for exceeding my own physical limits.
Printed Name:___________________________________________________Date:__________________________
Signature:_____________________________________________________________________________________
Cell phone #:____________________________Alternate phone #:________________________________________
E-mail address:_________________________________________________________________________________
CORE CONNECTIONS