Lovable App

Client Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

Occupation

Emergency Contact Name *

Emergency Contact Phone *

Primary Physician

Physician Phone Number

General Health Questions

Please select YES or NO for each item.

01.Has a doctor ever informed you that you have a heart condition or cardiovascular disease?

Yes No

02.Do you experience chest pain during physical activity?

Yes No

03.Have you experienced chest pain while at rest within the past 12 months?

Yes No

04.Do you lose balance because of dizziness or have you lost consciousness recently?

Yes No

05.Do you have any bone, joint, tendon, ligament, or muscular issues that could worsen with exercise or stretching?

Yes No

If YES, please explain

06.Have you had surgery within the past 12 months?

Yes No

If YES, please explain

07.Are you currently taking medications for blood pressure, heart conditions, blood thinning, pain management, anxiety, diabetes, or other chronic conditions?

Yes No

If YES, list medications

08.Has a healthcare provider ever advised you against participating in exercise or physical activity?

Yes No

09.Do you currently experience numbness, tingling, sciatica, nerve pain, chronic pain, or limited mobility?

Yes No

If YES, please explain

10.Are you currently pregnant or recently postpartum?

Yes No

If YES, how many weeks / months?

11.Do you have high blood pressure?

Yes No

12.Do you have diabetes or issues regulating blood sugar?

Yes No

13.Have you ever experienced seizures, respiratory conditions, asthma attacks, or exercise-induced breathing issues?

Yes No

If YES, please explain

14.Do you have any allergies or sensitivities relevant to exercise or manual contact?

Yes No

If YES, please explain

15.Have you recently experienced severe stress, fatigue, illness, injury, or hospitalization?

Yes No

If YES, please explain

Fitness & Lifestyle Information

Current activity level

SedentaryLightly ActiveModerately ActiveVery Active

Primary goals

Other goals

Areas of concern or discomfort

Previous training experience

NoneBeginnerIntermediateAdvanced

Assisted Stretching & Manual Contact Acknowledgement

Client understands assisted stretching and mobility sessions may involve:

Physical touch
Guided movement
Manual stretching
Myofascial techniques
Joint movement assistance
Postural adjustments

Client agrees to immediately communicate pain, discomfort, tingling, dizziness, shortness of breath, numbness, or any concerns during sessions.

I understand and consent to manual contact as described above.

Client Responsibility Acknowledgement

I understand it is my responsibility to:

Provide accurate medical information
Inform Cornerstone Fitness of changes in my health
Follow instructions during sessions
Exercise within my limits
Stop activity if symptoms occur

I understand failure to disclose medical conditions may increase my risk of injury.

Medical Clearance Recommendation

Cornerstone Fitness reserves the right to require physician clearance before participation if deemed necessary for safety.

Client Certification

I certify that the information provided is accurate and complete, that I voluntarily choose to participate, and that I understand this form does not replace medical advice.

I certify the above information is accurate and complete to the best of my knowledge.

Client Signature

Date *

Signature *

Cornerstone Fitness Representative

Full Name *

Date *

Signature *

PAR-Q & Medical Readiness

Client Information

General Health Questions

Fitness & Lifestyle Information

Assisted Stretching & Manual Contact Acknowledgement

Client Responsibility Acknowledgement

Medical Clearance Recommendation

Client Certification

Client Signature

Cornerstone Fitness Representative