Please complete the form below, or print a PDF version

    Gender
    MaleFemale

    Does your job require prolonged periods of sitting?
    YesNo

    Personal Fitness

    Presently, do you exercise on a regular basis?
    YesNo

    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

    Diet and Nutrition

    How would you describe your daily nutritional habits?
    unhealthyerratichealthy

    Medical History

    Are you currently under a doctor’s care?
    YesNo

    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.


    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.