Client Waiver Form

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    What is your present pain level? 1=lowest 10=highest 1 2 3 4 5 6 7 8 9 10

    List any surgeries have you had (Orthopedic, plastic, pregnancy, anything that cut skin)

    In the last year and currently, have you had any increases in stress in any of these areas? Give explanation only if you feel comfortable. It is important to realize emotional stress can play a major role in muscle inhibition and therefore can relate directly too many of the pains we feel in the body.

    Please list any and all injuries you have had (diagnosed, accidents, falls, etc.)

    How well do you sleep? PoorAverageGreatHow many hours of exercise do you perform in a week?0-22-44-66-88+Do you have a history of pain with exercise?YesNoPain that caused you to stop? YesNo

    Please list all doctors you are currently under care with (phone number if you have it readily available), please also list the type of doctor (ex. Orthopedic, Chiropractor, etc)

    This Questionnaire is not intended for use as a diagnostic tool. We recommend all clientsobtain a physical examination prior to beginning any exercise program or Muscle ActivationTechnique (MAT) sessions.

    The client understands that any exercise activity in which he/she engages is done athis/her own risk. It is expressly understood that Activation Fitness, Inc. will not be liable forinjuries or damages to client including without limitation, those injuries or damages resultingfrom acts of activity or passive negligence on the part of Activation Fitness, Inc. its successorsand assigns, as well as its owners, officers, employees and agents, from all such claims, injuriesor damages.

    MAT is a bodywork technique using a systematic approach to identifying and treatingmuscular imbalances that relate to injury.

    MAT addresses the component of muscle inhibition as a cause for limitations in joint range ofmotion. When muscles are inhibited, and/or have lost proprioceptive input, then the joint it supportsbecomes unstable. This instability must be identified and addressed. The MAT techniques aredesigned to identify and correct the positions of instability. When performed in this manner, thenatural protective mechanisms are diminished and normal joint motion occurs. The end result is thatwe are not only increasing joint motion, but we are also making sure that there is increased stabilitythrough that range of motion (Mobility and Stability). The client understands when MAT is utilized;they are not receiving physical therapy or chiropractic work.

    The undersigned certifies that he/she honestly and completely addressed each questionin the questionnaire, has read the questionnaire and the above paragraphs in their entirety, andfully understands them. The client understands and agrees that during the visit he/she is notreceiving physical therapy or chiropractic work.