• Senior Training•
Weight Lifters• Post-Rehab
Training• Online Training• Weight Gain• Weight Loss• Home/Office
Weight Equipment• Corporate
Online Training Health Questionnaire
* Fields Required
Physician's Name: (optional)
Physician's Phone: (optional)
person for emergency (name)
person for emergency (phone)
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? No Yes
*Describe your current exercise program and frequency:
*Describe your basic daily food consumption for a typical day: (Morning, Noon, Night,
*Do you now, or have you had in the past 10 years:
1. History of heart problems, chest pain or stroke. Yes No
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. Pregnancy (now or within last 6 months). Yes No
8. History of breathing or a lung condition. Yes No
9. Muscle, joint, or back disorder, or any previous injury still effecting you. Yes No
10. Diabetes or thyroid condition. Yes No
11. Cigarette smoking Yes No (If so, # packs per/ day)
12. Obesity (more than 20% over ideal body weight). Yes No
13. Increased blood bad cholesterol. Yes No
14. History of heart problems in immediate family. Yes No
15. Hernia, or any condition physical that may be aggravated by lifting weights. Yes No
If yes, please explain.
16. Rapid or runaway heartbeat. Yes No
17. Skipped heartbeat. Yes No
18. Rheumatic fever. Yes No
19. Phlebitis or embolism. Yes No
(blood clots and inflammation of veins)
20. Stroke. Yes No
21. Do you frequently have pains in your heart and chest? Yes No
22. Has any physician ever said you have heart trouble? Yes No
22. Has your doctor ever said you have heart trouble? Yes No
23. Do you often feel faint or have spells of severe dizziness? Yes No
24. Are you over age 65? Yes No
25. Are you unaccustomed to vigorous exercise? Yes No
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? Yes No
27. Orthopedic Problems Yes No
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
*What shape would you consider your body?
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?
*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)
Target Weight ( in pounds)
Muscle Toning Weight
Loss Strength Training
*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.
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!
Email : firstname.lastname@example.org
Notice Phone: 970-769-4583