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Nordic Balance - Abbeville Road
Nordic Balance - St. James's
Nordic Balance - Wimbledon Village
Nordic Balance - St John's Hill
Preferred location
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Another Client
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Local - Walking past
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How did you hear about us?
A few more details
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New injury with recent onset
No injury or pain
Ongoing injury 3 months or more
Post-surgery recovery
Recurring injury - comes and goes
What best describes your current condition? (optional)
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Improve mobility
Ongoing maintenance
Pregnancy-related care
Prepare for an event
Recover from injury or pain
Reduce stress or tension
Treatment for my child
What is your main goal for this visit? (optional)
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Foot or Ankle
Hands and Wrists
Head or Jaw
Hip, Glutes, Hamstrings
Knee
Lower Leg eg Calf
Lower back
Neck
Not applicable
Other
Pelvis
Quads
Shoulder or Arm
Upper back
Where is your primary area of concern? (optional)
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Foot or Ankle
Hands and Wrists
Head or Jaw
Hip, Glutes, Hamstrings
Knee
Lower Leg eg Calf
Lower back
Neck
Not applicable
Other
Pelvis
Quads
Shoulder or Arm
Upper back
Secondary area of pain or injury if applicable (optional)
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Cycling
Half or Marathon
Hyrox or CrossFit
Other
Racket sports
Team sports eg Rugby
Triathlon or Ironman
Ultra Marathon
Winter sports
5-10km Run
If preparing for an event, what is it? (optional)
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This month
Within 12 months
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Within 6 months
If preparing for an event, when is it? (optional)
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No
Yes
Do you spend most of your working day sitting at a desk? (optional)
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1-4 hours
5-8 hours
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If desk-based, how many hours a day? (optional)
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0
1-2 times
3-4 times
5 plus times
How often do you exercise per week? (optional)
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No
Yes
Do you run regularly? (optional)
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No
Yes
Are you pregnant? (optional)
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No
Yes
Are you preparing for an event or goal? (optional)
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No
Yes
Do you have any injuries? (optional)
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No
Yes
Do you smoke? (optional)
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No
Yes
Do you follow any special diet at present? (optional)
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Another Client
Email newsletter
Flyer or brochure
Google search
Insurance provider
Local - Other business or club
Local - Walking past
Referral - GP or specialist
Social Media
How did you find Nordic Balance? (optional)
What do you want to hear about?
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Account Management
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Schedule Updates
A heads-up before bookings or when you schedule changes
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News & Promos
Updates on events and our latest offers
Liability waiver
In checking the box below, I am agreeing that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in activity and use of equipment without the approval of my doctor and do hereby assume all responsibility for my participation and activities, and utilisation of equipment in my activities. I do hereby declare myself to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness that would prevent my participation or use of equipment or facilities except as herein stated. I understand that classes may be physically strenuous and I voluntarily participate in them with the full knowledge that there is a risk of injury, property loss or death. I understand that exercise and fitness activities involve a risk of injury, and that I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I understand that if I am pregnant, become pregnant or am post-natal I will make the instructors at Nordic Balance aware immediately and in checking the box I am verifying that I am participating in exercise and classes with my doctor’s full approval. I understand that I am participating in exercise and classes at my own risk and I hereby agree to expressly assume and accept all and any risks of injury or damage. If I choose not to take advice, or to disregard any advice so given, I do so voluntarily and accept liability for all resulting injuries or damage. I understand that if Nordic Balance believe me to be physically or mentally unfit to participate in a class or personal training session, then they reserve the right to refuse me entry. I agree that Nordic Balance reserves the right to refuse membership at their discretion. I understand that Nordic Balance may ask anyone who, in their opinion, disrupts or may disrupt any class without good reason to leave, and Nordic Balance reserve the right to terminate that person’s membership with immediate effect. I understand that Nordic Balance are in no way responsible for the safe keeping of my personal belongings whilst in attendance at the gym or classes. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Nordic Balance or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.
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