Introductory Health Assessment

 

Please complete the form below

Name *
Name
Referred to below as "Releaser"
Release of Liability
This release of liability is entered into by 413 Fitness and its employees and agents, hereinafter referred to as “Trainer” and “Releaser”. WHEREAS, Releaser desires to utilize the services of Trainer and designing/directing an exercise program and WHEREAS, Releaser understands that there are risks involved in such exercise program or activity, and being aware of such risks, is willing to release Trainer from any and all responsibility for injury or death resulting from these activities. NOW, THEREFORE, in consideration of the mutual covenants and consideration herein given, the parties hereto agree as follows: The Releaser has been advised that there are inherent risks, including serious injury or death which may result from any exercise activity. Further, the Releaser has been advised and understands that he/she should obtain a physical examination and/or receive his/her physician’s approval to exercise prior to beginning any exercise program or activity. 1. In consideration of the Releaser’s release of liability given herein, Trainer agrees to direct and/or assist Releaser in his/her exercise program or activity. 2. In consideration of the Trainer’s assistance, and understanding of the risks involved, Releaser expressly hereby releases Trainer from any liability for injuries, death, or damages to Releaser, without limitation, resulting from arising out of the result of any exercise program or activity which Trainer directs, assists, consults, or monitors Releaser. 3. Releaser further expressly agrees that any and all exercise activity in which he/she engages is done at his/her own risk. 4. Releaser’s release of liability given herein shall be binding upon Releaser’s heir, executors, or administrators. In addition to the agreement above, the Releaser also agrees to the following: 1. That the Releaser is physically sound and is suffering from no condition, impairment, disease, or other illness that would to his/her knowledge prevent participation in an exercise program. 2. In the event that the Releaser has need to cancel a session with the trainer due to illness, or any other situation, the Release agrees to pay in full the session amount to the Trainer if the Releaser fails to notify the Trainer within 24 hours advance.
Address *
Address
Home Phone
Home Phone
Cell Phone *
Cell Phone
Physician's Phone *
Physician's Phone
Phone *
Phone
Heart Health
1. Has your doctor ever said you have heart trouble, heart palpitation, coronary disease, or high blood pressure? *
2. Do you frequently experience pain or discomfort in the chest or heart area? *
3. Do you suffer from shortness of breath at rest or upon mild exertion? *
4. Do you suffer from dizziness or fainting? *
5. Do you have any difficulty breathing? *
6. Do you suffer from swollen ankles (due to circulation problems or metabolic condition)? *
If “yes” is the answer to any of the above please have physician complete medical clearance form prior to exercise
Risk Assessment
1. Has a physician ever diagnosed you as having high blood pressure (>160/90), or are you on blood pressure medication? *
2. Have you been diagnosed with high cholesterol? *
Is the value >240mg/dL?
3. Do you smoke? *
4. Do you suffer from diabetes? *
5. Has anyone in your immediate family suffered from coronary or atherosclerotic disease prior to the age of 55 years? *
6. Are you now or do you think you may be pregnant?
If “yes” to two or more of the above please have physician complete medical clearance form prior to exercise
Medical History
Do you have any physical limitations that would limit your ability to exercise? *
Lifestyle Assessment
Did you ever smoke? *
1 = relaxed, 10 = highly stressful
Do you practice any kind of stress management? *
BHAG's & Interesting Facts About You
We want to know what makes you tick!
Do you have a BHAG?
Big Hairy Audacious Goal
If you don't have a BHAG, we HIGHLY recommend you identify one. Training with a goal in mind leads to acting intently, instead of habitually.
Informed Consent
Testing/Exercise Objectives: I understand that the tests and/or exercises that are about to be administered to me are for the purpose of determining and/or developing my physical fitness status, including flexibility, muscular strength, muscular endurance, muscular power and agility. Explanation of Procedures: I understand that the tests and/or exercises, which I will undergo, may be performed indoors or outdoors. The tests and/or exercises are designed to, and will, increase the demands on the heart, lungs, vascular, muscular, and skeletal systems. Various static and dynamic exercise modalities may be employed to test or stimulate the multiple systems of the body. These include, but are not limited to: running, walking, plyometrics, free weights, resistive training machines, rubber bands, medicine ball training, etc. Description of Potential Risks: I understand that there exists the possibility that certain abnormal changes may occur during the testing and/or my exercise participation. These changes could include abnormal heartbeats, abnormal blood pressure response, various muscle and joint injuries, and in rare instances heart attack and death. Professional care throughout the entire testing and/or exercising session should provide appropriate precautions against such abnormal responses. However, these risks are still present and I have assumed the potential reward to be greater than that of potential risk. Benefits to be Expected: I understand that the results of any test administered to me will aid in: determining my current physical fitness/performance status, determining potential health hazards, and designing an appropriate exercise program. The exercises, which I will engage in, are designed to enhance the fitness parameters measured by the exercise tests, namely flexibility, muscular strength, muscular endurance, muscular power, and multidirectional speed and quickness. I have read the foregoing information and understand it. Questions concerning all procedures have been answered to my satisfaction. I also understand that I am free to deny answering any questions during the tests/exercise sessions. I have also been informed that the information derived from these tests are confidential and will not be disclosed to anyone other than my physician or others who are involved in my care or exercise prescription without my permission.
I pledge that all the information which I have provided in this form is accurate, to the best of my knowledge, and that I have not willingly excluded any important medical information which could have any bearing on my ability to safely engage in exercise testing and exercise participation.
Signature of Participant: *
Signature of Participant:
Date *
Date