Guest Form Jan 2016 NEW.pub

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Wellness Center, Navicent Health and Health Club, Navicent Health Guest Form STAFF USE ONLY

_______ Local _______ Out of Town _______ Blood Pressure

PLACE PICTURE ID HERE, Or attach to completed sheet

________ 1st Visit Date ________ 2nd Visit Date ________ 3rd Visit Date

Guest’s Name or Child’s Name & Child’s Date of Birth: ____________________________________________________DOB______________________ PARENT/GUARDIAN if applicable _______________________________________________ Address: _______________________________________________________________________

Home OR Cell Phone: ___________________________________________________ Work Phone: __________________________________________________________ **EMERGENCY CONTACT AND CONTACT NUMBER: _____________________________________________________________________ EMAIL ADDRESS:___________________________________________________________________________ CHECK ONLY THOSE THAT APPLY: Allergy _____ Arthritis _____ Bowel Polyps _____ Cancer _____ Cirrhosis _____ Diabetes _____ Gout _____ Heart Disease _____ High Blood Pressure _____ Kidney Disease _____ Lung Disease _____ Asthma _____ Bronchitis _____ Emphysema _____ Pneumonia _____ Nervous Disorder _____ Overweight _____ Seizures _____ Skin Rashes _____ Stroke _____ Surgery _____ Thyroid (Low/High) _____

MEDICATIONS: Hormones _____ Sleeping Pills _____ Sedatives _____ Tranquilizers _____ Thyroid _____ Insulin _____

Other Serious Health Problems: ______________________________________________ ______________________________________________ Physical Limitations or Restrictions: ______________________________________________ ______________________________________________ List all medicines you are currently taking: ______________________________________________ ______________________________________________ ______________________________________________ Any other health related information? _____________________________________________ ______________________________________________ ______________________________________________

Aspirin _____ Blood Pressure _____ Heart Medicine _____ Vitamins _____ Minerals _____ Other ________________

CHECK ALL SYMPTOMS THAT CURRENTLY APPLY: *Pain or discomfort in chest after exercising, eating, or exposure to cold _____ *Frequent Heart Palpitations or fluttering_____ *Unusual shortness of breath from brisk walking or climbing stairs_____ *Chronic Cough _____ *Frequent colds or flu (more than one time per year)_____ *Difficulty walking_____

*Frequent Dizziness _____ *Frequent Headaches_____ *Frequent aches or pain in joints_____ *Frequent backaches_____ *Frequent digestive upsets_____ *Pain in legs when walking or climbing upstairs_____

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GUEST LIABILITY RELEASE It is agreed and understood that all activities, exercise, use of equipment and facilities shall be undertaken by guest at their sole risk and Center shall not be liable any claims, demands, actions, or causes of action, to guests or their property arising out of or connected with the sue of any of the services and facilities. Guest forever expressly release, indemnify and hold harmless Wellness Center, Navicent Health /Health Club, Navicent Health and their respective agents, servants and employees for any and all liability, whatsoever. Guest affirms that their state of health permits them to participate in Center activities. Guest also affirms that they have completed a Health History Questionnaire. The guest agrees to abide by all rules and regulations, to use good personal health judgments and to use proper safety skills at all times. WARNING: IF YOU HAVE A HISTORY OF HEART DISEASE OR DISEASE SUBJECT TO AGGRAVATION BY EXERCISE, YOU SHOULD CONTACT THE FITNESS INSTRUCTOR ON DUTY OR CALL PRIOR TO PARTICIPATION IN CENTER ACTIVITIES, EXERCISE, OR EQUIPMENT USE. SIGNATURE OF GUEST (or Guardian)

______________________________________________________________ DATE______________________________________ WITNESS ______________________________________ Updated Jan 1, 2016