2. Increased blood pressure. Yes No

3. Any chronic illness or condition. Yes No

4. Difficulty with physical exercise. Yes No

5. Advice from physician not to exercise. Yes No

6. Recent surgery (last 12 months). Yes No

If so, Please explain or list any recent surgeries.

7. Recent hospitalization for any cause. If so please explain? Yes No

8. Pregnancy (now or within last 6 months). Yes No

9. History of breathing or lung problems. Yes No

10. Muscle, joint, or back disorder, or any previous injury still effecting you. Yes No

11. Diabetes or thyroid condition. Yes No

12. Cigarette smoking. Yes No (If so, # packs per/ day)

13. Obesity (more than 20% over ideal body weight). Yes No

14. Increased blood bad cholesterol. Yes No

15. History of heart problems in immediate family. Yes No

16. Hernia, or any condition that may be aggravated by lifting weights. Yes No

17. Rapid or runaway heartbeat. Yes No

18. Skipped heartbeat. Yes No

19. Rheumatic fever. Yes No

20. Phlebitis or embolism. Yes No (blood clots and inflammation of veins)

21. Stroke. Yes No

22. Do you frequently have pains in your heart and chest? Yes No

23. Has any physician ever said you have heart trouble? Yes No

24. Has your doctor ever said that you have heart trouble? Yes No

25. Do you often feel faint or have spells of severe dizziness? Yes No

26. Are you over age 65? Yes No

27. Are you unaccustomed to vigorous exercise? Yes No

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? Yes No

29. Orthopedic Problems Yes No

30. Do you feel drops in your energy throughout the day? Yes No

31. Are you currently doing cardiovascular exercise? Yes No

32. How many days a week, does exercise fit into your lifestyle? One Two Three Four Five Six Seven

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? Yes No

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? --Please Select One-- Yes No