About You
Let's get started with some basic information about you.
Name *
Name
Phone Number *
Phone Number
Birthday *
Birthday
Home Address *
Home Address
Emergency Contact
Who should I call if something should happen to you?
Emergency Contact's Phone Number *
Emergency Contact's Phone Number
Employment
Please complete this section if you are currently employed.
Business Phone Number
Business Phone Number
Physician
Physician Phone Number
Physician Phone Number
May I have permission to contact your physician regarding your health status?
Date of Your Last Physical
Date of Your Last Physical
Family Medical History
The following medical issues have been seen in my family:
Check the medical issues that your parents or siblings have had.
If you checked anything above, please provide more details such as who and their age at the time of occurrence. Please also add any other medical conditions that may run in your family.
Personal Medical History
Conditions You Have (Past and Present)
Check the conditions you currently have. If a condition occurred in the past, please check it and indicate how long ago in the details section below.
Any other issues? Any recent illness, hospitalization or surgery?
Do you smoke? *
If so, are you trying to quit or open to quitting?
History of Osteoporosis
Last Bone Density Test?
Last Bone Density Test?
Please enter your spine, hip, and wrist T-scores:
History of Breast Surgery
Please complete this section if you have ever had breast surgery
Date of Surgery
Date of Surgery
Did you have an axillary node dissection?
Physician Phone Number
Physician Phone Number
That can provide medical clearance for your exercise program
Orthopedic History
Describe any bone, joint or muscle injuries that you presently have or have had in the past (i.e neck, shoulder, elbow, low back, hip, knee problems).
Physical Activity
Do you engage in physical activity on a consistent basis? *
How long have you done this routine?
Have you exercised in the past? *
What Are Your Personal Fitness Goals? *
Survey Questions
Health Related Behaviors
Health Related Behaviors
How true are the following statements?
I want to improve my overall health
I want to improve my overall fitness
I want to improve my activity level
I want to improve my energy level
I want to improve my weight
I want to improve my body fat
I want to improve my eating habits
I want to improve my blood pressure
I want to improve my stress managment
I want to improve my time management
I want to improve my sleeping pattens
I want to decrease my alcohol consumption
I'd like to have a more positive attitude
Electronic Signature Needed
INFORMED CONSENT: PHYSICAL FITNESS PROGRAM *
General Statement of Program Objectives and Procedures: I understand that this physical fitness program may include exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle strength, endurance and flexibility; bone mass), and to improve body composition (decrease of body fat with an increase in weight of muscle and bone). Exercises may include aerobic activities (treadmill walking/running, bicycle riding, stair climbing, rowing machine exercise, etc.), calisthenics and weight lifting to improve muscular strength and endurance, and stretching exercises to improve flexibility. Description of Potential Risks: I understand that the reaction of the heart, lung and blood vessel system to such exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate, ineffective functioning of the heart, and in rare instances, heart attacks. Use of the weight lifting equipment and engaging in heavy body calisthenics can lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression and safety procedures are not followed. Description of Potential Benefits: I understand that a program of regular exercise for the heart and lungs, muscles and joints has many associated benefits. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in psychological function and a decrease in risk of heart disease. I have read the foregoing information and understand it; any questions which have occurred to me have been answered to my satisfaction. Any information obtained during the course of the training sessions will be treated as privileged and confidential and will not be released or revealed to any person other than my physician without my expressed written consent.
WAIVER AND RELEASE OF ALL CLAIMS BY CLIENT *
The CLIENT acknowledges that any program of fitness exercise involves a risk of injury. The CLIENT represents that he/she has been recently examined by a medical doctor and been found able to undertake a program of exercise. For and in consideration of the design of an exercise program for CLIENT by Joan Pagano (“TRAINER”), CLIENT agrees: that any exercise program shall be undertaken by CLIENT at his/her sole risk; and that TRAINER shall not be liable to CLIENT, nor any other person, for any claims or causes of action whatsoever (including injury or damages resulting from acts of active or passive negligence) arising out of or connected with the services of TRAINER; and that CLIENT hereby releases and discharges TRAINER from any such claims or actions.
ALL INFORMATION IS TRUE *