Name:

E-mail:

Phone (Home):

Phone (Work): (optional)

Address:

Weight (in pounds):

Height:

Physician's Name: (optional)

Physician's Phone: (optional)

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 exercise program now:

Describe your daily food consumption for a typical day:
(Morning, Noon, Night, Snacks)

Do you now, or have you had any of the following in the past 5 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

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

8. Pregnancy (now or within last 3 months). Yes No

9. History of breathing or lung problems. Yes No

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

11. Diabetes or thyroid condition. Yes No

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

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

14. Increased blood 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

21. Stroke. Yes No

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

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

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

25. Are you over age 65? Yes No

26. Are you unaccustomed to vigorous exercise? Yes No

27. Has your doctor ever said that you have heart trouble? 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

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

In consideration of my participation in a Nutrition, Fitness & Weight Training with Darin and Fitness and Body Image. I do hereby agree to hold free from any and all liability Fitness and Body Image, Darin, his heirs, anyone he may represent, for myself, my heirs, executors and administrations, waive release and 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. And hereby swear that all my answers to the above questions are correct to the best of my knowledge.

Do you agree to these terms? --Select One-- Yes No