Please note: If you are under the age of 18, you will need to complete our paper application with a signature of a parent or guardian.

Emergency Contacts
YesNo
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?

If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. During your medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Medical/Exercise History

Agreement and release of liability for WellSpan Results Therapy & Fitness

The undersigned knowledge that he/she is voluntarily participating in an exercise/fitness activity and the use of exercise equipment and machinery. I agree that there is inherent risk in any such activity and I agree to release Results Therapy and Fitness, its officers, agents, representatives, and employees from any and all liability, damages, or expense which I have or may have against Results Therapy and Fitness arising from or relating to any accident or injury I may sustain while engaging in this activity.

I further understand and have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have at least yearly physician examinations and consultations with my physician as to physical activity, exercise, and the use of exercise and training equipment. I acknowledge that I have either had a physical examination and have been giving my physician’s permission to participate, or that I have decided to participate in this activity and use of equipment and machinery without approval of my physician. I agree to assume all responsibility for my participation and utilization of equipment and machinery in my activities.