Do you have a family history of cardiovascular disease? If so, how many occurrences and what approximate ages? _______________________________________________________________________
Are you a smoker? If so, what is your smoking frequency? _____________________________________
Are you on any specific food / nutritional plan at this time? _____________________________________
Do you take dietary supplements? If yes, please list ___________________________________________
How many beverages do you consume per day that contains caffeine? ___________________________
Do you experience any frequent weight fluctuations? __________________________________________
Have you experienced a recent weight gain or loss? ___________________________________________
If yes, list change ___________________________________Over how long? _________________________
Your answers to these questions will be discussed with you prior to your session. Thank You.
Please take a moment to carefully read the following information and sign where indicated.
I understand that the personal training I receive is provided for the purpose of exercise instruction and guidance. I further understand that personal trainers are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, or provide nutritional planning, and that nothing said in the course of the session(s) given should be considered as such. I should see a physician, chiropractor, registered dietitian or other qualified medical specialist for any nutritional concerns, mental or physical ailment that I am aware of. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the personal trainer updated as to any changes in my medical profile, and understand that there shall not be liability on the personal trainer’s part should I forget to do so. I understand that I have enrolled in the personalized health and fitness program offered through Holistic Fitness & Massage LLC, The Salon, Spa & Fitness Studio, and/or Franck’s Gym and it’s personal trainers and affiliates. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I herby affirm that I am in good physical condition and do not suffer from any know disability or condition which would prevent or limit my participation in this exercise program. I acknowledge that my enrollment and subsequent participation in purely voluntary and in no way mandated by Holistic Fitness & Massage LLC, The Salon, Spa & Fitness Studio, and/or Franck’s Gym and it’s personal trainers and affiliates. In consideration of my participation in this program, I hereby release Holistic Fitness & Massage LLC, The Salon, Spa & Fitness Studio, and/or Franck’s Gym and it’s personal trainers and affiliates from any claims, demands, and causes of action as a result of my voluntary participation and enrollment of the provided personal training services and/or exercise classes. I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program and I hereby release Holistic Fitness & Massage LLC, The Salon, Spa & Fitness Studio, and/or Franck’s Gym and it’s personal trainers and affiliates from any liability now or in the future for conditions that I may obtain. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that I may incur, including death. I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS.
Consent for minors is required prior to first session.
Signature of Guardian____________________________________________ Date _____________________
Printed name of Guardian __________________________________________________________________
Phone number the Guardian can be reached in case of emergency __________________________________