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Senior Training
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*Name:

*E-mail:

*Phone (Home): *Phone (Cell)

Phone (Work):  *Current Age:

*Address:

Physician's Name: (optional)

Physician's Phone: (optional)

*Contact person for emergency (name)

*Contact person for emergency (phone)

*Contact person for emergency (relationship)

*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 basic daily food consumption for a typical day:
(Morning, Noon, Night, Snacks)

*Do you now, or have you had 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. Pregnancy (now or within last 6 months).

8. History of breathing or a lung condition.

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

10. Diabetes or thyroid condition.

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

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

13. Increased blood bad cholesterol.

14. History of heart problems in immediate family.

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

If yes, please explain.

16. Rapid or runaway heartbeat.

17. Skipped heartbeat.

18. Rheumatic fever.

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

20. Stroke.

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

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

22. Has your doctor ever said you have heart trouble?

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

24. Are you over age 65?

25. Are you unaccustomed to vigorous exercise?

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

27. Orthopedic Problems

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

29. Are you currently doing cardiovascular exercise?

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

*What shape would you consider your body? Pear Apple Other If other, Please explain:

*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?      

*If yes, what is your time frame? (Weeks, Months, Years)

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

*Your Personal Fitness Goals

Present Height (feet/inches) Weight (in pounds) Target Weight ( in pounds)

Muscle Toning Weight Loss Strength Training Sports Conditioning Injury Rehabilitation

Bodybuilding Other

 

*If I have any of the following medical conditions, I will need to first see my personal physician and get approved before I can continue with any online fitness training programs offered by fitness and body image. 

Heart Disease                            Anemia                     Hypoglycemia                  Liver Disease                                   Kidney Disease                       Diabetes             Pancreatic Disease             Lactation       Hypertension

 

In consideration of my participation in a Online Nutrition and/or in-person, 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 any Fitness and Weight Training Program offered to me.

 **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:
Physical
Mental
Spiritual

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!