Medical History Form

Welcome to PerformanceRx. It is important that you complete the following medical history form as accurately as possible. This is so that we can offer you the best possible service specifically tailored to your requirements. All information entered on this form is strictly private and confidential. Thank you for allowing PerformanceRx to take care of your personal health and wellbeing. Please note that all information is secure and is stored on an encrypted server.

 

Please complete the form below

Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Medical History *
Please check all that apply to you Have you had/suffered or been diagnosed with any of the following:
Please list all medications you are currently taking
Please describe any joint or muscles injuries/pain that you currently experience
Thank you for taking the time to complete the medical history form and general questionnaire. All this information will be used and analysed by PerformanceRx which will enable us to design a health and exercise program suited to your needs and goals. PerformanceRx has a strict client privacy clause and will protect and treat all of the above information with the utmost confidentiality. I have answered the questions accurately and correctly. I understand that my medical history is an important factor in the development of my exercise and fitness program. Health and fitness is not an exact science and no guarantees can be made as to the safety of exercise activities. I understand that known, unknown or undisclosed medical or physical conditions may result in injury. I knowingly and willingly assume all risks, and I hereby release PerformanceRx from any and all liability, damage, or loss arising/or resulting from my participation in this exercise program.