Please complete the form below, or print a PDF version
First Name
Last Name
Address
Your Email
Your Phone
Emergency Contact
Gender MaleFemale
Age
Height
Weight
Occupation
Does your job require prolonged periods of sitting? YesNo
Personal Fitness
Presently, do you exercise on a regular basis? YesNo
What are your current fitness related goals?
If you are trying to lose weight, how many pounds do you want to get rid of?
Assign a number 1 through 5 to rate the following statements according to your perception of the following (1 represents the lowest level, 5 represents the highest level)
-How fit you currently feel 12345
-Your capacity for aerobic activity 12345
-Your muscular strength 12345
-Your body’s flexibility 12345
-Your current level of energy 12345
How often do you want to work out? DAYS PER WEEK
How often do you want to work out? MINUTES PER SESSION
List any exercises you are either unable or unwilling to do?
List any injuries that would inhibit an exercise program. List date/year injury began to inhibit exercise if relevant.
Diet and Nutrition
How would you describe your daily nutritional habits? unhealthyerratichealthy
List any medications you take on a regular basis. Include vitamins and supplements.
Medical History
Are you currently under a doctor’s care? YesNo
If yes, explain:
Have you ever had an exercise stress test? YesNo
Have you recently been hospitalized? YesNo
Do you smoke? YesNo
Are you pregnant? YesNo
Do you consider your stress level to be high? YesNo
Do you have any of the following (check all that apply)? high blood pressurehigh cholesteroldiabetesknown heart diseasea heart murmurchest pain during physical activityirregular heart beat or palpitationslightheadedness or fainting spellsunusual shortness of breathcramping pains in legs or feetemphysemathyroid or kidney disordersepilepsyasthma
Do you have any other health issue or limitation not yet mentioned? YesNo
Participant Assumption of Risk
In consideration of volunteering to participate in personal fitness training at Studio Fitness, I (for myself and on behalf of my heirs) assigns, personal representatives and next of kin hereby assume the risk and release and hold harmless Results Fitness and its employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct fitness related activities (“Releasees”), with respect to all and any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law. It is understood that I am in no way releasing Studio Fitness from any actions which amount to willful or malicious conduct or gross negligence.
I understand that an activity of this type carries a significant risk of injury, including the potential for permanent paralysis and death, and accept the risk for participation. I have fully and accurately completed a health screening form. A physician’s examination should be obtained by all before involvement. After having consulted a physician or doctor, I agree to observe all restrictions for exercise that were given by this physician or doctor.
I have been advised that by gradually progressing toward a strenuous exercise program, I will minimize the risk of injury or accident. I further understand that Studio Fitness does not purport to act as my medical advisor and is not qualified to diagnose the medical condition or physical abilities of each of its participants, such as myself. I agree to be fully responsible for monitoring my exercise intensity during each training session, and I expressly agree to assume the risk of any injuries or accidents arising out of my participation in the exercise program.
I have read this entire Assumption of Risk and fully understand its terms. I further state that I am of lawful age and legally competent to sign this affirmation and release; that I understand the terms herein and not a mere recital; and that I have signed this document as my own free act.
Full Name
Date
Commitment I understand that in order for maximum benefit and noticeable progress to occur, I must follow my trainer’s nutritional advice and a prescribed workout regimen that will include exercise on days that I do not meet with my trainer. Should I be in the position of needing to reschedule a session, I will do so with a minimum of 12 hours notice. Short of an emergency, neglecting to do so will result in the usual session fee.
