Form - Vera Vigh ovement coach

Initial questionnaire

Initial questionnaire and consent

This information will help me understand where we're starting and where you'd like to go. It will allow me to focus on the most relevant assessments and personalize your exercises. Please add details and additional information where relevant.

Name

Phone

Year of birth

Occupation (what activity do you spend your day doing)

What would you like to achieve from our work together?

What methods and techniques have you tried so far, and with what results?

Method or technique A

Method or technique B

Method or technique C

List injuries, accidents, illnesses, and surgeries, including operations involving general anesthesia, in your life (including when, even if they are apparently unrelated or if it happened a long time ago)

Have you ever had

Header

Spinal injury

Seat belt trauma

None of these

Describe the trauma:

Do you wear glasses or contact lenses, or do you have vision problems? (Describe, including the prescription for each eye)?

Dental work?

Do you have any other sensory problems? (hearing, smell, loss of sensation, or neuropathy)

Describe what exactly?

Two

muscle weakness

joint pain

joint instability

none of these

if yes, please describe it (e.g. weakened right hand grip)

Do you have scars, tattoos, piercings? (If so, please describe)

Do you have any chronic illnesses? (Describe: for example, high blood pressure, thyroid problems, allergies, food intolerances, etc.)

List any medications or supplements you are taking:

Informed Consent & Liability Waiver

1. Massage Therapy Services * I understand that the massage and bodywork provided are for the purpose of stress reduction, relief from muscular tension, and overall well-being. * I understand that the massage therapist does not diagnose illness, disease, or any physical or mental disorder. * I will immediately inform the practitioner of any discomfort so that the pressure or technique can be adjusted. * I am aware that I may stop the session at any time.

2. Fitness Training Services * I understand that physical exercise and fitness training carry an inherent risk of injury. * I acknowledge that it is my responsibility to consult with a physician prior to participating in any fitness program. * I will inform my trainer of any changes in my physical condition. * I voluntarily assume all risks of damage or harm that may arise during or as a result of my participation.

3. Cancellation Policy & Payments * Sessions must be canceled or rescheduled at least \(24\) hours in advance; otherwise, the full session fee applies.

In compliance with GDPR, your personal data is securely stored and processed only as necessary to manage appointments, administer treatments, and design safe fitness programs. Your data will be used solely for appointment confirmations, reminders, or schedule changes, unless you provide separate consent for other communications. You may request access, correction, portability, or deletion of your data at any time.

Stay in the Loop (Without the Spam)

By consenting, you agree to receive the occasional reminder to book your next session, plus updates about workshops, classes, and special offers — never more than about once a month. No spam, no flooding your inbox, and absolutely no selling your information to third parties. You can unsubscribe anytime, no hard feelings.