Bodywell by Danielle Fit University
Email address *
Name *
Your answer
Do you have parental permission? *
Required
Phone *
Your answer
Date of Birth *
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DD
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YYYY
College/High School Name *
Your answer
Are you accustomed to exercise and/or physical activity on a regular basis? *
Have you had surgery or been hospitalized in the past year? Have you been in physical therapy for an injury? If so please explain.... *
Your answer
Do you have any of the following conditions: Check all that apply. *
Required
Do you take any medications? If so please list all..... *
Your answer
Do you smoke? *
On average, how many alcoholic drinks do you consume per week? *
Please list any medical related issues, concerns or information why you potentially should NOT participate in this program. *
Your answer
What are your favorite ways to be active and workout? *
Required
How many days per week do you stay active and/or workout? *
Do you belong to any sports teams, dance teams or activity clubs you will no longer be involved with in college? If so please explain... *
Your answer
How often do you change your fitness routine, nutrition choices and try new things? *
What are your goals? Check all that apply. *
Required
How do you usually workout and stay active? *
What does mobility and stability mean to you? What are functional movement patterns? Answer as best you can. *
Your answer
What do you do for recovery and rest days? Do you know how to foam roll? Do you stretch? *
Your answer
Have you ever been injured or pulled a muscle? What do you do when you are very sore or feel pain? *
Your answer
What types of diet do you follow? *
Required
List a typical day of food you eat, beverages you drink, etc.... *
Your answer
Do you take any supplements or vitamins on a regular basis? Please list all..... *
Your answer
Have you ever tried cryotherapy, infrared sauna, epsom salt bath, normatec compression? *
Required
Where do you look for fitness, nutrition, wellness advice? *
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Who do you follow on Social Media for fitness, nutrition and wellness? List a few accounts you find most helpful, and a few you find confusing or offering things that don't work for you.... *
Your answer
What do you need the most guidance on? For example: Are there trends you follow that don't yield results? Are there foods you are eating that don't agree with your stomach? Are there supplements your friends are trying that you are not sure you should be taking? Do you do the same workout every day? Are you unable to make time to stay active? *
Your answer
What are your biggest hurdles that get in the way of achieving your goals? How do you plan your schedule long term or short term? *
Your answer
Liability Release: The Health History Profile is not a substitute for a thorough physical examination, assessment and diagnosis by your physician. It has been designed to identify individuals for whom physical activity might be inappropriate at this time. Before starting any type of physical conditioning program it is always best to have a complete physical exam. Only after your doctor has given you clearance to exercise, should you begin any type of conditioning program that involves vigorous or strenuous exercise. I hereby understand that I will be participating in a program with Danielle Bogaty. I understand that she is unaware of my physical or mental condition upon commencement of the program. I realize that it is my responsibility to determine that I am capable of undergoing physical activity and take ultimate responsibility of what recommendations/advice I choose to follow. Because the effects of the program depend in part upon the efforts of the individual, results will vary from person to person. Danielle makes no warranties, guaranties, or claims regarding the extent of the benefits that any individual may derive from the program. I understand that the nature and purpose of the program requires me to engage in activities or lifestyle changes and I am aware that any such changes can involve risks. I hereby assume the risk of any and all accidents, injuries, set backs, illnesses, negative outcomes of any kind that may be sustained by me by reason of or in connection with my participation in the program. I hereby release, discharge and absolve Danielle Bogaty from any and all liability, responsibility, future claims, actions, damages, losses, costs and expenses of any kind whatsoever from participating in the program, except to the extent it results from gross negligence or willful misconduct by Danielle Bogaty. *
Required
If under 18 parent must AGREE to waiver as well so please list parent name and phone below. *
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