1.  Athena Rehab, LLC Amy Brown, Rehab Specialist NAME_____________________________________ M ____ F_____ ADDRESS ____________________________________ CITY ___________________ OR__________ ZIP ____________ HOME PHONE __________CELL PHONE ____________________ DATE OF BIRTH _____________________ AGE _______ DRIVERS LICENSE # ___________________________________ EMPLOYER NAME ____________________________________ OCCUPATION/ POSITION ______________________________ EMERGENCY CONTACT________________________________ PHONE # ___________________________________________

2. Athena Rehab, LLC Name:_________________________________ MEDICAL HISTORY FORM Height ___ ’____” Weight ________ lbs.Blood Pressure_____Have you ever had surgery? ____ Yes ____ No If yes, please describe and give dates:______________________________________________________________________________________________Have you had physical therapy for your present condition?____Yes____No If yes, please describe:______________________________________________________________________________________________________________Have you ever received other treatments for your presentcondition? ____Yes____No______________________________________________________________________________________________________________Are you presently taking any medication?______Yes _____NoPlease list:_______________________________________Do you have any metal anywhere in your body?Do you have a cardiac pacemaker?Are you pregnant?Do you have any trouble with vision?Do you have any trouble with hearing?Do you now have, or have you ever had any of the following:Diabetes, High Blood Pressure,Heart Disease, Heart Attack,Headaches, Kidney Problems, Nervous Disorders, Circulationproblems, Back or neck pain, Stress, Sensitive to heat/ice, Allergies,Hernia, Broken Bones, Sprained Joints, Seizures, Dizzy Spells,Muscle aches or painPlease explain any Yes answers and give approximate dates: __________________________________________________________________________________________________Brieflydescribe your condition:DATE OF INJURY:____________________________________________________________________________________________________________The above information is accurate and complete, to the best of myknowledge.Signature:_______________________________Date_______

3. Athena Rehab, LLC Name

4. Athena Rehab, LLC  Name:___________________________________________  Health & Fitness Liability Waiver / Informed Consent Form  “I, _______________________________, have enrolled in thepersonalized health and fitness program offered throughAthena Rehab LLC. I recognize that the program may involvestrenuous physical activity including, but not limited to, musclestrength and endurance training, cardiovascular conditioningand training, and other various fitness activities. I hereby affirmthat I am in good physical condition and do not suffer from anyknown disability or condition which would prevent or limit myparticipation in this exercise program. I acknowledge that myenrollment and subsequent participation in purely voluntaryand in no way mandated by Amy Brown or Athena Rehab.”  “In consideration of my participation in this program, I,_________________________, hereby release Athena Rehab,Amy Brown,and its agents from any claims, demands, andcauses of action as a result of my voluntary participation andenrollment.”  “ I fully understand that I may injure myself as a result of myenrollment and subsequent participation in this program and I,___________________________________, hereby releaseAthena Rehab, Amy Brown, and its agents from any liabilitynow or in the future for conditions that I may obtain. Theseconditions may include, but are not limited to, heart attacks,muscle strains, muscle pulls, muscle tears, broken bones, shinsplints, heat prostration, injuries to knees, injuries to back,injuries to foot, or any other illness or soreness that I mayincur, including death.”  I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTANDTHE ABOVE STATEMENTS.  ___________________________ (Participant Signature)___________________________ (Date)

5. Athena Rehab, LLC Name _________________________ Initial Functional Screen

6. Athena Rehab, LLC NAME:_______________________________________________DATE: Time In/Out:S:O:A:P:DATE: Time In/Out:S:O:A:P: