Personal Training

Chair Massage


Full Name*
Date
Address*
City*
State*
ZIP Code*
Phone
Cell
Work*
Email*
Occupation*
Date of Birth
Age
Emergency Contact
Emergency Contact Phone
Which Bootcamp Are you interested in?
Gender
Height feet    inches
Weight lbs.
General and Medical Information

Please complete the following general and medical history form PRIOR to your first visit. All information will be confidential. This information, in conjunction with a physical assessment will be used to design a comprehensive program that meets your goals and needs. Many health benefits are associated with regular exercise, and the completion of the following questions is a sensible first step to take if you are planning to increase the amount of physical activity in your life. The questions have been designed to identify if physical activity might be inappropriate or if you should have medical advice concerning the type of activity most suitable for your individuality. It is important to fill out the form carefully and thoroughly. Thank you.

Yes No Questions
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Do you know ANY other reason why you should not do physical activity?
Does your occupation require extended periods of sitting?
Yes No Questions
Does your occupation require extended periods of repetitive movements? (If yes, explain below)
Does your occupation require you to wear shoes with a heel (dress shoes)?
Does your occupation cause you anxiety (mental stress)?
Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, explain below)
Do you have any hobbies? (If yes, explain below)
Have you ever had any pain or injuries? (If yes, explain below)
Have you ever had any surgeries? (If yes, explain below)
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, explain below)
Are you currently taking any medication? (If yes, explain below)
Please specify the personal importance of the following goals.

Very
Important		 Somewhat
Important		 Not so
Important		 Goal
Improved Strength
Fat Loss
Build Muscle
Bodybuilding
Rehabilitation
Reduce Back Pain
Injury Prevention
Reduce Stress
Very
Important		 Somewhat
Important		 Not so
Important		 Goal
Improve Cardiovascular Fitness
General Fitness
Improved Function
Tone-up
Post-Rehabilitation
Improve Sports Performance
Improve Flexibility
Increase Energy
Specify sport(s) and/or
other training objectives
not listed
Are you currently involved
in a regular exercise program? 		 Yes       No
(If yes, please list how
long and what type of exercises)
How many days a week
can you dedicate to your
individualized program?
How much time PER SESSION
can you dedicate to your
program?
What other activites outside
of your conditioning program
will you be participating in?
Please read the Policy Agreement, the Medical Waiver and the Professional Agreement.