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New Member Health/Wellness Questionnaire and Contract 

Please fill out the following form.

Date of birth

Please note: The following information is required to assess your physical fitness level and to establish your exercise prescription. Your health questionnaire and test results are confidential and will not be released to anyone other than yourself. 

Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes

Have you ever experienced any of the following while walking, working or exercising? (check Yes or No) 

Pain in the chest
No
Yes
Faintness/ Light headed
No
Yes
Faintness/ Light headed
No
Yes
Heart beat irregularities
No
Yes
Pain in the neck
No
Yes
If so, what side (left or right): _______________________________
Pain in the lower back
No
Yes
If so, what side (left or right): _______________________________
Leg Pain
No
Yes
If so, what side (left or right): _______________________________
Shortness of breath
No
Yes
Confusion/ Dizziness
No
Yes
Persistent cough
No
Yes

 To your knowledge do you have or have you had any of the following? (check Yes or No) 

Diabetes
No
Yes
Pulmonary disease
No
Yes
Gout (elevated uric acid)
No
Yes
Stroke
No
Yes
Anemia-low red blood cell count
No
Yes
Varicose Veins
No
Yes
Heart murmur, angina, heart attack, coronary, arteriosclerosis
No
Yes
Heart/Cardiopulmonary disease
No
Yes
Asthma, emphysema, bronchitis
No
Yes
Thyroid, Kidney or Liver disease
No
Yes
Rheumatic fever
No
Yes
Hernia
No
Yes
AIDS or HIV Positive
No
Yes

Have you recently experienced any of the following: 

Localized muscle soreness
No
Yes
Flare-up of old injuries
No
Yes
Noticeable loss of muscle size
No
Yes
Joint Stiffness
No
Yes
Loss of local muscle strength
No
Yes
Restricted joint movement
No
Yes

Has your personal physician indicated that you have: 

High Blood Pressure
No
Yes
If yes, please indicate: Systolic__________ Diastolic _____________
Elevated Blood Cholesterol
No
Yes
If yes, please indicate level _______________________
Do you smoke a pipe, cigars or cigarettes?
Yes
No
If yes: # per day____________ # of years

If you used to smoke, how long has it been since you quit

(indicate days/months/years)? _________________________

Do you consume alcoholic beverages?
Yes
No
If yes (check): __ daily __ weekly __ monthly
Do you diet?
Yes
No
If yes, why? weight loss ________ weight Gain __________ medical Explanation: _____________________________________________________________________________________________________________________

Liability Waiver

The undersigned recognizes that the use of Wellness Studio M’s services involves an inherent risk of physical injury including that caused by a sudden and unforeseen malfunctioning of exercise equipment, or the negligence of the undersigned, of Maria Tokarz, of Wellness Studio M, or of contractors and employees of Wellness Studio M (“Studio M Agents”). The undersigned hereby agrees to assume the risk of injury in its entirety regardless of the cause. Wellness Studio M and Studio M Agents shall not be liable for injuries or damages to the undersigned, or the property of the undersigned, or be subject to any claim, demand, injury, death, or damages whatever, including, without limitation, those damages resulting from acts of negligence on the part of Wellness Studio M and Studio M Agents for all such claims, demands, injuries, death, damages, actions, or causes of action. It is specifically agreed that Wellness Studio M and its Agents shall not be responsible or liable to the undersigned for articles lost or stolen in connection with services provided by Studio M or its Agents. Because physical exercise can be strenuous and subject to a risk of serious injury, all participants are urged to obtain a physical examination from a doctor before using any exercise equipment, participating in any exercise activity, or following any recommendations for a dietary or food supplement change.

Audio/Photo/Video Media Release Form

I grant permission to Wellness Studio M, and its agents or employees to use photographs and/or video and audio taken of me.  These images may be used in promotional and advertising materials and may be used online in materials such as a website, YouTube or similar site or online newsletter.

Furthermore, I authorize the use of my image, likeness, and voice for all promotion, materials, and any other purposes in connection with the business of Wellness Studio M or the activities of Wellness Studio M or its principal, Maria Tokarz deemed appropriate by Wellness Studio M or Ms. Tokarz. 


I hereby agree to release, defend, and hold harmless Wellness Studio M and its agents or employees, including Maria Tokarz and any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.


I am 18 years of age or older and have read this release before signing below, fully understanding the contents, meaning, and impact of this release.  I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

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