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? No Yes

Describe your current exercise program and frequency:

Describe your basic daily food consumption for a typical day: Morning, Noon, Night, Snacks:
Skip this question if, a detailed nutrition is only allowed by a registered dietitian in your state of residence. **(Otherwise, highlight this paragraph and delete it to type yourself)**

Do you now, or have you had 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. Pregnancy (now or within last 3 months). Yes No

8. History of breathing or lung problems. Yes No

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

10. Diabetes or thyroid condition. Yes No

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

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

13. Increased blood cholesterol. Yes No

14. History of heart problems in immediate family. Yes No

15. Hernia, or any condition that may be aggravated by lifting weights. Yes No

16. Rapid or runaway heartbeat. Yes No

17. Skipped heartbeat. Yes No

18. Rheumatic fever. Yes No

19. Phlebitis or embolism. Yes No

20. Stroke. Yes No

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

22. Has your physician 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

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

In consideration of my participation in a Nutrition, 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 the Fitness and Weight Training Program. I agree that all training packages payments are non-refundable unless the trainer is not able to make it. 

 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? Yes No