Waiver & Health History Questionnaire


Member Name:
Address:

Mark Yes or No

  1. Have you ever had any form of heart disease?  
  2. Have you ever experienced shortness of breath or chest pains?  
  3. Date of last full physical examination  
  4. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?  
  5. Do you feel pain in your chest when you do physical activity?  
  6. Do you lose your balance because of dizziness or do you ever lose consciousness?  
  7. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?  
  8. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?  
  9. Do you know of any other reason why you should not do physical activity?  

Do you have any or do any of the following pertain to your health? If yes, explain.

High blood pressure?  

Cigarette smoking?  

Diabetes?  

Family history of diabetes?  

Do you exercise at least three times per week?  

Are you currently taking any medication?  

I, , agree to participate in one or more physical fitness program(s)/class(es) provided by ​me360​, which may include, but not necessarily be limited to cardiovascular training, weight lifting, high intensity interval training, and/or training of any kind by any affiliate, subsidiary or partnership of ​me360 and/or ​me360

(hereinafter collectively referred to as ​me360​). ​me360 made me fully aware that the fitness programs/classes which ​me360 offers and in which I desire to participate are of a nature and kind that may be extremely strenuous and can/may push me to the limits of my physical abilities. I, the undersigned, recognize and understand that the programs/classes are not without varying degrees of risk which may include, but are not limited to the following:

Injury to the musculoskeletal and/or cardio respiratory systems which can result in serious injury or death, injury or death due to negligence on the part of myself, my training partner, or other people around me, injury or death due to improper use or failure of equipment, or injury or death due to a medical condition, whether known or unknown by me. I am aware that any of these above-mentioned risks may result in serious injury or death to myself and or my partner(s).

I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in ​me360 programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness program. I hereby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by ​me360​. ​me360 informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. ​me360 informed me that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in ​me360​ fitness programs/classes.

In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily participating in the activities made available by ​me360​, and with my full understanding of all of the above, I hereby waive, release, remise and discharge ​me360 and its agents, officers, principals, independent contractors, partners, employees and volunteers, of any and all liability, claims, demands, actions or rights of action, or damages of any kind related to, arising from, or in any way connected with, my participation in ​me360 fitness programs/classes, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties.

This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.

I recognize that there is risk involved in the types of activities offered by ​me360​. Therefore I accept financial responsibility for any injury that I may cause to myself due to negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless ​me360​, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by ​me360​.

The information on this me360 “platform” (“platform” refers to all me360 websites, apps, zoom calls, telephone calls, in-person seminars or any other information given by me360) is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through the platform is for general information purposes only. me360 makes no representation and assumes no responsibility for the accuracy of information contained on or available through this platform, and such information is subject to change without notice. You are encouraged to confirm any information obtained from or through this platform with other sources, and review all information regarding any medical condition or treatment with your physician. NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING YOU HAVE READ ON OR ACCESSED THROUGH THIS PLATFORM.

me360 does not recommend, endorse or make any representation about the efficacy, appropriateness or suitability of any specific tests, products, procedures, treatments, services, opinions, health care providers or other information that may be contained on or available through this web site. me360 IS NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT YOU OBTAIN THROUGH THIS PLATFORM.

Me360 is a fitness and coaching platform.  Me360 does not provide medical services directly. If you so choose to schedule an appointment for a medical evaluation, treatment or any other type of service directly with one of our independent practitioners, you are 100% responsible for any fees, co-pays or any type of expense incurred by said service, test, treatment, product, evaluation.   Many of the practitioners affiliated with me360 are independent practitioners and are neither employees nor agents of me360. As a result, me360 is not responsible for the care provided by these practitioners.

 

Use of picture(s)/film/likeness: I agree to allow ​me360​, its agents, officers, principals, employees and volunteers to use picture(s), film, screenshots and/or likeness of me for advertising purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform ​me360 of this in writing via email to​ mleonardi@me360health.com ​with subject: ​SOCIAL MEDIA CONSENT​.

I have fully read and fully understand the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waivingvaluable legal rights.

Leave this empty:

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Signed by Michael Leonardi
Signed On: April 14, 2021


Signature Certificate
Document name: Waiver & Health History Questionnaire
lock iconUnique Document ID: 39b2e3f7bd77793c5dc87dcf626b99997b2d2841
Timestamp Audit
March 8, 2021 1:24 pm EDTWaiver & Health History Questionnaire Uploaded by Michael Leonardi - mleonardi@me360health.com IP 99.24.222.23
April 14, 2021 4:24 pm EDT Document owner ellie@rawfitnesspersonaltraining.com has handed over this document to mleonardi@me360health.com 2021-04-14 16:24:11 - 99.24.222.23