Name * First Name Last Name Email * Date of Birth * MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Please answer below health questions: * 1. Has your doctor ever told you that you have a heart condition or have ever suffered a stroke? YES NO * 2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? YES NO * 3. Have you ever felt faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? YES NO * 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? YES NO * 5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? YES NO * 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? YES NO * 7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? YES NO Are you currently experiencing any muscle or joint pain or any other area of concern? Please provide detail below What is your current goal and when would you like to acheve this by? * Please provide detail below If you answer “YES” to any of the 8 questions, please seek guidance from your Doctor or appropriate health professional prior to undertaking physical activity/exercise. PLEASE INITIAL AND PROVIDE FURTHER INFO BELOW * In the following cases of diseases or conditions, it is forbidden to undergo EMS Training. I understand and accept to be bounded by the contents of all of the above mentioned declarations.. Please consult your Doctor prior to participating in EMS Training. Do you currently experience the following? * Do you have a Cardiac pacemaker or implanted defibrillators? YES NO * Are you currently pregnant? Or breast feeding? YES NO * Do you have a Neurological Disorder - Any disorder of the nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord or other nerves YES NO * Have you experienced seizures or convulsions? YES NO * Do you have severe neuromuscular disorder (e.g. rhabdomyolysis or any disorder that affects the nervous system and the muscles and causes rapid breakdown in muscle structure). YES NO * Do you have severe nephrological disease (e.g: Kidney disease) YES NO * Have you had any cancerous lesions in the past 5 years (e.g. breast cancer) YES NO * Do you have Multiple Sclerosis? YES NO IMPORTANT NOTES- Please read carefully the conditions listed below before starting your training with EMS technology: In case of malaise, ailment, dizziness or feeling aching tightness around the chest or heart area you must inform the trainer to immediately stop the training If you feel any hotness or discomfort on your skin during the training, you need to ask the trainer to switch off the device. There will be reflex-like muscle contraction movements caused by stimulation impulses. Maintain pre-contracted muscles if possible and acquire a stable basic position. Ensure proper water intake before and after training. If you feel necessary, have a short break during the training and drink a glass of water. Make sure that you had a proper meal 2-4 hours before your training. EMS training might cause micro tears in the muscles, which usually leads to muscle soreness, and elevated creatine kinase (CK-MM) level in the blood. This is a natural reaction of the human body to intensive trainings (such as EMS trainings). In case you have your blood analysed 2-6 days after your last EMS training it is important to inform your doctor to prevent incorrect misinterpretation of your values. DECLERATION I declare to undergo EMS training willingly and through my own responsibility. I declare myself to be able to undergo EMS training with respect to my current mental state, health and physical status. I declare that I am not aware of any contraindication (described above) that may exclude me from the training. I declare that I have received any and all obligatory medical consultations for the circumstances described above. I declare to inform my physician and EMS Trainer in case of any change in my mental, physical and health status. I declare to inform my doctor or any other Medical professional involved in my care, in case of any medical intervention of undergoing EMS training. I declare that in case of omitting or noncompliance with the terms of this agreement I undergo the training fully and completely through my own responsibility. I declare that I will not hold XLAB EMS Training Trainer responsible if any of my unknown mental, health or physical conditions cause side effects or complications of any kind. I declare to follow the instructions given by XLAB EMS Training Trainer before, during and after the training. I provide consent that my personal and training data will be registered and used as a client of XLAB EMS Training. Please initial in acknowledgement of the above detail in its entirety * I understand and accept to be bounded by the contents of all of the above mentioned declarations. Date MM DD YYYY Thank you! <
