Health Forms - Personal & Group Training

Participant Info

First Name *

Last Name *

Date of Birth *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email Address *

Opt-in to get reminders about classes!

Emergency Contact Info

First Name *

Last Name *

Relationship to Participant *

Phone Number *

Medical History

Do you have any of the following conditions? *

List the medications/supplements you are presently taking and what they are for: *

Have you ever had surgery? If so, when and what? *

Please check any conditions that are present in your family: *

Exercise History

Are you currently exercising regularly (at least 3x a week)? *

Yes

No

--- If yes, fill in the following chart with the type of exercise and duration.

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
Type/Duration	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.

--- If no, have you ever been on a regular exercise plan?

Yes

No

If you have exercised on a consistent basis previously, how long ago was this and how long did it last? *

What type of exercise do you prefer (i.e. walking, tennis, yoga, hiking, etc.)? *

Can you currently walk 1 mile without fatigue? *

Yes

No

Can you currently walk 4 miles without fatigue? *

Yes

No

Do you strength train? *

Yes

No

If yes, what types of equipment do you use (i.e. Free weights, stability balls, medicine balls, cardio equipment, etc.)

Nutrition History

In general how do you feel about your nutritional habits? *

Do you follow or have you recently followed any specific dietary intake plan? Fad Diets? *

How often do you eat a balanced meal (proteins, carbohydrates, fruit, vegetables, healthy fats, dairy)? *

Do you drink alcohol? *

Yes

No

If yes, how much and how often?

Lifestyle History

What do you do for a living? *

On average how many hours of sleep do you get a night? *

Do you smoke? *

No

Yes (how much per day/ at what age did you start) Yes (how much per day/ at what age did you start)

Are you a primary caregiver for children, individuals with disabilities, or an elderly relative? *

Are you experiencing any stressors, mood problems, relationship difficulties, or substance related problems? *

Goals

Given the following goals, please rank them in order of importance, with 1 being the most important and 7 being the least important.

	Improved health
	Improved endurance
	Increased strength
	Increased flexibility
	Weight Loss
	Weight Gain
	Sport Specific

Do you have a specific time line for achieving your goals? If so, please explain. *

Check which type of progress is important to you. *

Immediate progress that is less easily maintainable

Maintainable progress that may not be as rapid

What time do you prefer to meet and work out with a personal trainer? *

Before 8:00am

Mid-morning

Afternoon

After 5:00pm

How many times per week do you want to work out with a trainer? *

1x

2x

3x

4+

Would you prefer to train by yourself or with a partner? *

Self

Partner

Anything else you want me to know about you?

Terms & Conditions

By checking the box below, I agree to the following:

Total payment to Life Training is due at the beginning of each training series.
Personal training sessions that are not rescheduled 24 hours in advance will result in forfeiture of the session and a loss of the financial investment.
Clients arriving late will receive the remaining scheduled session time, unless other arrangements have been previously made.
Life Training has permission to add my email to the newsletter.
I give Life Training my permission to use my photograph, image, name and likeness in all forms and media.
As a parent or legal guardian, I give Life Training permission to use the minor’s photograph, image, name, and likeness in all forms and media.

*

I agree

Liability Release

Life Training is making trainers available to you in order to provide you (“Participant”) with health related services. By signing below, you acknowledge and agree to the following terms:

I represent that I am physically fit to participate in all activities and that, prior to participation, I have consulted a physician regarding any limitations or medical risks that I may have and I hereby certify that I am free from any such limitations or medical risks. I further agree that performing physical activity involves certain risks. The risks include, but are not limited to, serious bodily injury and death. With full knowledge of the potential of these risks, I voluntarily choose to take part in the all activities and hereby release and waive all claims of liability on behalf of Life Training, regardless of whether such injury or death was due to negligence (of any kind) on the part of Life Training.

I have read the forgoing and understand that by checking the box below, I am giving up certain legal rights and remedies.

*

I agree

Arthritis	Low Back Pain	Calcium Deposits
Neck Injury	Hip/Pelvis Injury	Ankle/Foot Injury
Arm/Elbow Injury	Nerve Damage	Bone Fracture
Shoulder Injury	Knee Injury	Back Pain
Wrist/Hand Injury	High Blood Pressure	High Cholesterol
Hyper or Hypothyroid	Type 1 or Type 2 Diabetes	Other: Other:

Heart attack	Stroke
High blood pressure	High cholesterol
Type 1 or Type 2 Diabetes	Other Major Illness Other Major Illness