Fitness & wellness — participation discussion

Discussion aid for private-pay fitness and wellness. This is separate from physical therapy treatment consent. No information is saved or sent by this blank page. Practice review is needed before use.

Consent information

Participant / date / providerPlanned fitness or wellness activities and goalsRelevant health issues, precautions and assistance neededExpected benefits, personal risks, alternatives and questions discussed

Exercise and wellness activities may cause fatigue, soreness, symptom flares, dizziness, loss of balance or injury. The plan should reflect my health, abilities and goals. I may pause, decline an activity or request a change. I will report new symptoms and ask if instructions are unclear. Benefits are not guaranteed. This agreement does not authorize unrelated medical procedures or use of my image in advertising.

Decision and requested limitsParticipant or authorized representative signature / dateRepresentative authority, if applicableProvider signature / date