Athena Rehab, LLCAmy Brown, Rehab Specialist

NAM

E_____________________________________

M ____ F_____

ADD

RESS ____________________________________

CITY ___________________ OR__________ ZIP ____________ H

OM

E

PHO

NE __________CELL PH

ON

E ____________________ DATE OF BIRTH

_____________________ AGE _______

DRIVERS LICEN

SE # ___________________________________

EMPLO

YER NAM

E ____________________________________

OCCU

PATION

/ POSITIO

N ______________________________

EMERG

ENCY CO

NTACT________________________________ PH

ON

E #

___________________________________________

Athena Rehab, LLC

Nam

e:_________________________________

MED

ICAL HISTO

RY FORM

Height ___ ’____” W

eight ________ lbs. Blood Pressure_____H

ave you ever had surgery? ____ Yes ____ No

If yes, please describe and give dates: ______________________________________________________________________________________________ H

ave you had physical therapy for your present condition? ____Yes____No

If yes, please describe: ______________________________________________________________________________________________________________H

ave you ever received other treatm

ents for your present condition? ____Yes____No

______________________________________________________________________________________________________________Are you presently taking any m

edication? ______Yes _____N

oPlease list:_______________________________________Do you have any m

etal anywhere in your body?

Do you have a cardiac pacemaker?

Are you pregnant?Do you have any trouble w

ith vision? Do you have any trouble w

ith hearing?Do you now

have, or have you ever had any of the following:

Diabetes, High Blood Pressure ,H

eart Disease, Heart Att

ack, Headaches,

Kidney Problems, N

ervous Disorders, Circulation problems, Back or neck

pain, Stress, Sensitive to heat/ice, Allergies, Hernia, Broken Bones, Sprained

Joints, Seizures, Dizzy Spells, Muscle aches or pain

Please explain any Yes answers and give approxim

ate dates: __________________________________________________________________________________________________Briefly describe your condition: DATE O

F INJU

RY:__________ __________________________________________________________________________________________________

The above information is accurate and com

plete, to the best of my

knowledge.

Signature:_______________________________Date_______

Athena Rehab, LLC

Nam

e

Athena Rehab, LLC

Nam

e:___________________________________________

Health &

Fitness Liability Waiver / Inform

ed Consent Form

“I, _______________________________, have enrolled in the personalized health and fitness program

offered through Athena Rehab LLC. I recognize that the program

may involve

strenuous physical activity including, but not limited to, m

uscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I hereby affi

rm that I am

in good physical condition and do not suffer from

any known disability or condition w

hich would prevent or

limit m

y participation in this exercise program. I acknow

ledge that m

y enrollment and subsequent participation in purely

voluntary and in no way m

andated by Amy Brow

n or Athena Rehab.”

“In consideration of my participation in this program

, I, _________________________, hereby release Athena Rehab, Am

y Brown,and its agents from

any claims, dem

ands, and causes of action as a result of m

y voluntary participation and enrollm

ent.”

“ I fully understand that I may injure m

yself as a result of my

enrollment and subsequent participation in this program

and I, ___________________________________, hereby release Athena Rehab, Am

y Brown, and its agents from

any liability now

or in the future for conditions that I may obtain. These

conditions may include, but are not lim

ited to, heart attacks,

muscle strains, m

uscle pulls, muscle tears, broken bones, shin

splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that I m

ay incur, including death.”

I HEREBY AFFIRM

THAT I H

AVE READ AN

D FU

LLY UN

DERSTAN

D

THE ABO

VE STATEMEN

TS.

___________________________ (Participant Signature) ___________________________ (D

ate)

Athena Rehab, LLCN

ame _________________________

Initial Functional Screen

Athena Rehab, LLCN

AME:_______________________________________________

DATE: Time In/O

ut:

S:O:

A:P:DATE: Time In/O

ut:

S:O:

A:P: