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Specialized For Local Area, Fitness Training Programs

General In Gym Fitness Training Programs

Specialized For Local Area, Business Fitness Training Programs


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Phone (Home):  Phone (Cell): (optional)

Phone (Work): (optional)  Current Age:


Weight (in pounds):

Current Height:

Physician's Name: (optional)

Physician's Phone: (optional)

Are you taking any medications or drugs? If so, what?

Does your physician know you are participating in this exercise program?

Describe your current exercise program and frequency:

Describe your daily food consumption for a typical day:
(Morning, Noon, Night, Snacks)

Do you now, or have you had any of the following in the past 10 years:

1. History of heart problems, chest pain or stroke.

2. Increased blood pressure.

3. Any chronic illness or condition.

4. Difficulty with physical exercise.

5. Advice from physician not to exercise.

6. Recent surgery (last 12 months).

If so, Please explain or list any recent surgeries.

7. Recent hospitalization for any cause. If so please explain?

8. Pregnancy (now or within last 6 months).

9. History of breathing or lung problems.

10. Muscle, joint, or back disorder, or any previous injury still effecting you.

11. Diabetes or thyroid condition.

12. Cigarette smoking. (If so, # packs per/ day)

13. Obesity (more than 20% over ideal body weight).

14. Increased blood bad cholesterol.

15. History of heart problems in immediate family.

16. Hernia, or any condition that may be aggravated by lifting weights.

17. Rapid or runaway heartbeat.

18. Skipped heartbeat.

19. Rheumatic fever.

20. Phlebitis or embolism. (blood clots and inflammation of veins)

21. Stroke.

22. Do you frequently have pains in your heart and chest?

23. Has any physician ever said you have heart trouble?

24. Has your doctor ever said that you have heart trouble?

25. Do you often feel faint or have spells of severe dizziness?

26. Are you over age 65?

27. Are you unaccustomed to vigorous exercise?

28. Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?

29. Orthopedic Problems

30. Do you feel drops in your energy throughout the day?

31. Are you currently doing cardiovascular exercise?

32. How many days a week, does exercise fit into your lifestyle?

When did you start thinking about getting in shape?

What stopped you in the past from getting in shape?

Where do you rate health in your life?

Low Priority   1   2    3   4    High Priority

Do you have a time frame for achieving your goals?

What is your time frame?

Please explain any "Yes" answers or include your comments:

Your Personal Fitness Goals

Target Weight ( in pounds)

Muscle Toning Weight Loss Strength Training Sports Conditioning Injury Rehabilitation

Bodybuilding Other

I hereby swear that all my answers to the above questions are correct to the best of my knowledge. In consideration of my participation in a Nutrition, Fitness & Weight Training, Post-Rehab, Home Weight Equipment, Training Elderly, Weight Loss, Weight Gain Programs, Weight Loss Program and all Future Fitness Training Programs Offered by Darin (Owner) and Fitness and Body Image. I do hereby agree to hold free from any and all past and future liability, Fitness and Body Image, Darin (owner), his/their heirs, anyone he may represent, for myself, my heirs, executors and administrations, waive release, waive any option to sue, forever discharge any and all rights and claims for damages which I may have or which may hereafter accrue to me arising out of or connected with my participation in the Fitness and Weight Training Program. I agree that all training packages payments are non-refundable unless the trainer is not able to make it. 

Please type your full name in box

By typing my name I hereby swear that all my answers to the above questions are correct to the best of my knowledge and agree to all the terms, hold free all liability from the training party, as stated above

Do you agree to these terms?


Health and Fitness Code:

Please consult your physician before performing any exercises.

At any time during your workout, if you feel faint, dizzy, loss of breath, or extra tired: Stop Exercising Immediately!