Personal Information

Name (required):

Height:

Weight:

Gender you identify with:

Age:

Birthdate:

Address:

City:

State:

ZIP:

Phone (required):

Emergency Contact:

Emergency Phone:

Personal Physician:

Physician Phone:

Email (required):

Health History Questions

1. Have you ever had a definite or suspected heart attack or stroke?

YesNo

2. Have you ever had coronary bypass surgery or any other type of heart surgery?

YesNo

3. Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)?

YesNo

4. Do you have a history of: diabetes, thyroid, kidney, liver disease (check all that apply)

DiabetesThyroidKidneyLiver Disease

5. Have you ever been told by a health professional that you have had an abnormal resting or exercise (treadmill) electrocardiogram (EKG)?

YesNo

If you answered YES to any of Questions 1 through 5, please describe:

Current Symptoms

7. Do you currently have any of the following:

Pain or discomfort in the chestShortness of breathUnexplained dizziness or faintingDifficulty breathing at night except in upright positionSwelling of the anklesHeart palpitationsPain in the legs (claudication)Known heart murmur

Have you discussed any of the above with your personal physician?

YesNo

Are you pregnant or is it likely that you could be pregnant at this time?

YesNo

If yes, what is your expected due date?

Have you had surgery or been diagnosed with any disease in the past 3 months?

YesNo

If yes, please list date and surgery/disease:

Additional Health Information

Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?

YesNo

Do you currently smoke cigarettes or have quit within the past 6 months?

YesNo

Have your father or brother(s) had heart disease prior to age 55 OR mother or sister(s) had heart disease prior to age 65?

YesNo

Within the past 12 months, has a health professional told you that you have high blood pressure (systolic > 140 OR diastolic > 90)?

YesNo

Currently, do you have high blood pressure or, within the past 12 months, have you taken any medicines to control your blood pressure?

YesNo

Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 100 mg/dl?

YesNo

Describe your regular physical activity or exercise program:

Frequency: days per week

Duration: minutes

Intensity: LowModerateHigh

BMI:

If you have answered YES to any of questions 7-16, please describe:

Additional Medical Conditions

Are you currently under any treatment for any blood clots?

YesNo

Do you have problems with bones, joints, or muscles that may be aggravated with exercise?

YesNo

Do you have any back/neck problems?

YesNo

Have you been told by a health professional that you should not exercise?

YesNo

Are you currently being treated for any other medical condition by a physician?

YesNo

Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia, hepatitis, etc.) that may hinder your ability to exercise?

YesNo

During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)?

YesNo

If you have answered YES to any of questions 18-24, please describe:

Please list below all prescription and over-the-counter medications you are currently taking:

Are there any medicines that your physician has prescribed to you in the past 12 months which you are currently not taking?

YesNo

If so, please list:

Agreement

I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my fitness/wellness program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my trainer, may result in serious injury to me. If any of the above conditions change, I will immediately inform my trainer of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire. I also understand that in order to properly risk stratify my Health History Questionnaire, my trainer should have a minimum of a national certification as a personal trainer. My trainer also verbally explained this statement to me to my understanding.

Client's Signature (required):

Date (required):

Trainer’s Signature:

Date:

Exercise Objectives

The purpose of an exercise program is to develop and maintain cardio respiratory (aerobic) fitness, muscular strength and endurance, body composition, and flexibility. These recommendations follow industry standards and should be conducted under the supervision of a trainer with a minimum if a national certification.

Procedures

A structured exercise program based on individual needs (obtained fitness assessment information), interests, and/or physician’s recommendations will be given to each participant. Exercises may include aerobic activities (treadmill walking/running, cycling, rowing machine exercise, group aerobic activity, swimming, and other such activities), calisthenics, and weight lifting to improve muscular strength and endurance, and flexibility to improve joint range of motion. All aerobic programs improve warm-up, exercise at target heart rate, and cool-down components and follow The American College of Sports Medicine’s recommendations.

Potential Risks

All exercise programs/testing are designed to gradually increase workload on the cardio-respiratory and musculoskeletal systems in order to effect improvements. The body’s reaction to gradually increasing exercise activities cannot be predicted with complete accuracy. Unusual changes during or following an exercise session may occur. These may include muscular or joint injury, abnormal blood pressure, fainting, disorders of heartbeat, and/or very rare instances of heart attack or death.

Potential Benefits

Benefits obtained from structured and regularly employed exercise program might include a more efficient cardio respiratory system, an improved musculoskeletal system, a decrease in body fat, a decrease in blood fats, an improvement in psychological function, and a decrease in the risk of heart and other diseases.

Supervision

Your trainer is not responsible for injuries and/or damages that occur when the facility/individual(s) are not supervised by your trainer or during non-operation hours.

Confidentiality

All personal Participant exercise program information will be treated as confidential and will not be revealed to any person (other than the trainer or instructor involved in the Participant’s exercise program) without express written consent. Obtained information, however, may be used for statistical or scientific purposes with right to privacy retained.

Inquiry and Freedom of Consent

I have read the foregoing and I understand the objectives, procedures, potential risks and benefits, supervision issues, and confidentiality involved. Unless otherwise indicated under the “comments” section below, I certify that I am in good health and have no condition that would limit/prohibit my participation in a structured exercise program. I understand that if there are any questions about the procedures or methods used during an exercise session, I should ask the trainer. I realize that injury may result from improper exercise techniques or misuse of exercise facilities or equipment. I agree to be attentive to all instructions given to me and to exercise and use facilities and equipment correctly. I assume responsibility for monitoring my own condition throughout the exercise program and should any unusual symptom(s) occur, I will cease participation and inform the trainer. I shall also notify the trainer of any changes in my medical status. I consent to administration of any immediate resuscitation measures deemed advisable by my trainer or other qualified personnel.

Questions/comments:

I have read and understand the above information and voluntarily consent to participate in a structured exercise program. I realize that I am free to terminate the exercise program at any time.

Printed Name:

Signature:

Date: