Wellness Assessment (V1.1)
Please fill out your information below!
How Did You Hear About Us?:
Reason for wanting to experience OsteoStrong? (Please check all that apply):
Joint & back pain
Type 2 diabetes
Overall health and wellness
Please rate your level of physical activity
Under chiropractic care?
If yes, where?
Do you have a primary physician?
If yes, who?
I am currently taking medication for.. (Please check all that apply):
Metabolic dysfunction (ie; thyroid)
Have you had a full body DEXA scan?
If yes, date of last scan?
Diagnosis of DEXA Scan?
Have you lost any height?
If so, how much?
Do any of the following apply to you? (Please check all that apply) :
*Prohibited from engaging in the OsteoStrong exercise system. People with high blood pressure or hypertension that is treated through medication may be cleared to do OsteoStrong sessions. Always talk to your doctor before engaging in physical activity.
Third trimester pregnancy*
Have you ever been treated for:
Do you have recent or existing medical procedures, surgeries, sprains, broken bones, or muscle conditions that could have an impact on your body while doing an OsteoStrong session? If Yes, Please explain below. Medical conditions from the above question. required ,
Please confirm your consent by typing your name into each field below, you may be required to sign again in person during your first appointment.
I state that I am physically capable of participating in a weight-bearing exercise resistance training program or OsteoStrong exercise system.
I have either received permission from my doctor to perform any type of exercise listed above and the OsteoStrong exercise system OR I have decided to participate in the OsteoStong program without consulting my physician even though OsteoStrong recommends all members concerned about exercising should consult a physician.
I assume all responsibilities for my decision to engage in the OsteoStrong program. I will not hold any OsteoStrong center of OsteoStrong Franchising, LLC, the owners, principles, partners, agents, affiiates, contractors, employees, patent company of subsidiaries liable or responsible for any physical injuries or mental anguish that I may experience as a result of my participation with the OsteoStrong exercise system. I state that I am physically and mentally capable of using the equipment. If I am a parent of legal guardian signing on behalf of a minor, I am stating that the minor is physically capable of performing exercise.
I understand that sessions at OsteoStrong do not treat or diagnosis any disease condition.
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