Name *

First Name

Last Name

Phone *

(###)

###

####

Today's Date *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

TRAINING PROGRAM POLICIES *

*Sessions are scheduled for fifty minutes. To get the most out of our efforts, please be ready to exercise at the scheduled time. *To keep studio safe and clean, please change into your workout shoes once you arrive at the studio. *Please wear comfortable clothing that facilitates ease of movement. *We adhere to strict sanitizing policies and do not feel we can adequately clean shared mats, please bring an exercise mat for your personal use. *As a professional courtesy, there will be no charge on sessions cancelled with more than 24 hours notice. Card on file will be charged $40 for sessions cancelled between 24 to 2 hours prior to appointment. Appointments cancelled less than 2 hours before the start or no shows, will be charged the session price. *Credit card must be on file to reserve trainer’s time and studio space.

By checking this box and signing this form, you agree to the TRAINING PROGRAM POLICIES listed above.

Gender *

Male

Female

Age *

<45

45 to 54

>55

High blood pressure (e.g., systolic equal to or over 140 and/or diastolic equal to or over 90) *

Yes

No

Elevated or abnormal blood lipids (e.g., cholesterol, triglycerides, LDL, HDL, etc.) *

Yes

No

Smoke cigarettes or former smoker who has quit in the last six months. *

Yes

No

Overweight (e.g., waist circumference over 40 inches for men and 35 inches for women) *

Yes

No

Sedentary (e.g., do not exercise at all or perform less than 150 minutes of moderate activity weekly) *

Yes

No

Elevated blood sugar (e.g., levels greater than 100 mg.d1) *

Yes

No

History of heart disease (e.g., father/ first degree male relative under age 55 or mother/first degree female relative under age 65 *

Yes

No

Has your physician ever told you that you have a heart condition and that you should only do physical activity recommended by a physician? *

Yes

No

Do you experience pain in your chest or radiating into your jaw, neck or arms when you are physically active? *

Yes

No

In the past three months have you experienced chest pain at rest or when asleep? *

Yes

No

Do you lose balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you experience shortness of breath at rest or with mild exertion? *

Yes

No

Is your physician currently prescribing medications for your blood pressure, blood lipids or a heart condition? *

Yes

No

Do you or have you experienced recently swelling in the ankles or other extremities? *

Yes

No

Do you experience pain or severe discomfort in your lower extremities when walking that subsides within 1 to 2 minutes after you stop? *

Yes

No

Do you have diabetes? *

Yes

No

Do you have asthma or another respiratory condition that causes difficulty with breathing? *

Yes

No

Do you currently or have you experienced within the past 6 months back pain/discomfort or other joint related problem that prevented you from carrying out normal daily activities? *

Yes

No

Are you pregnant? *

Yes

No

By checking this box, you agree to the terms *

I agree to the terms and conditions outlined in this form