Using the WaiverElectronic system to search and download the digital waivers for trianing and see the exact numbers of signed waivers.

PERSONAL TRAINING IN-TAKE FORM 

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? Please check it here.

Do you frequently have pains in your chest when you perform physical activity? Please check it here.

Have you had chest pain when you were not doing physical activity? Please check it here.

Do you lose your balance due to dizziness or do you ever lose consciousness? Please check it here.

Do you have a bone, joint or any other health problems that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporasis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia anemia, epilepsy, respiratory aliments, back problems, etc.)? Please check it here.

Are you pregnant now or have you given birth within the last 6 months? Please check it here.

Have you had a recent surgery? Please check it here.

If you have marked YES to any of the above, please elaborate Please enter your answer here.

Do you have any chronic illness or physical limitations such as Asthma, diabetes? *

Yes

No

Please select at least one choice above.

Do you have any injuries or orthopedic problems such as bursitis, bad knees, back, shoulder, wrist or neck issues? *

Yes

No

Please select at least one choice above.

Do you take any medications, either prescription or non-prescription, on a regular basis? *

Yes

No

Please select at least one choice above.

If Yes, please specify Please enter your answer here.

If Yes, What is the medication? Please enter your answer here.

How does this medication affect your ability to exercise or achieve your fitness goal? Please enter your answer here.

Lifestyle Related Questions

Do you smoke? Please check it here.

If you do, how many a day? Please enter your answer here.

Do you drink alcohol? Please check it here.

If yes, how many glasses per week? Please enter your answer here.

How many hours do you regularly sleep a night? Please enter your answer here.

Describe your Job *

Sedentary

Active

Physically Demanding

Please select at least one choice above.

Does your job require you to travel? *

Yes

No

Please select at least one choice above.

On a scale of 1-10 how would you rate your stress level? *Please enter your answer here.

List your 3 biggest sources of stress *Please enter your answer here.

Is anyone in your family overweight?

Mother

Father

Sibling

Grandparent

Please select at least one choice above.

Where you overweight as a child? *

Yes

No

Please select at least one choice above.

If yes what age? *Please enter your answer here.

Your signature *

Click to sign

Please sign here.