New Client Forms-FitnessBeyondTrain

New Client Forms

Please fill out this form with as much detail as possible, so we can provide an excellent service.

First Name

Last Name

Phone Number

Address

Birthdate/Age

Emergency Contact

What services are you interested in?

How did you hear about us?

Revised Physical Activity Readiness Questionnaire (PAR-Q)

Please answer Yes or No to the following questions:

Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?

Yes

Have you ever had angioplasty, cardiac bypass, or stints?

Yes

Do you have chest pain brought on by physical activity?

Yes

Have you developed chest pain in the past month?

Yes

Have you on one or more occasions lost consciousness or fallen over as a result of dizziness?

Yes

Do you have a bone or joint problem that could be aggravated by physical activity?

Yes

Has a doctor ever recommended medication for your blood pressure or a heart condition?

Yes, my blood pressure is controlled withing a normal range

Yes, but my blood pressure is GREATER than 145/90 mm Hg

Are you aware, through your own experience or a doctor’s advice, of any other physical reason that would prohibit you from exercising without medical supervision?

Yes

Agreement and Release of Liability

Please read this information now. You will be asked to initial each section at your next appointment.

In consideration of being allowed to participate in physical activity and the use of the services of Fitness Beyond Training, LLC, I do hereby knowingly and voluntarily forever waive, release, and discharge any or all claims or liabilities for injuries or damages to my person and/or property arising out of or connected to my participation in any activities or programs given by the fitness professionals of Fitness Beyond Training, LLC

I have been informed, understand, and am aware that exercise, including the use of exercise equipment, is potentially hazardous. I am voluntarily participating in these activities and understand the dangers involved. I hereby agree to expressly consume and accept any or all risks of injury or death.

I do hereby consider myself to be physically sound and suffer from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of exercise equipment. I do hereby acknowledge and have been informed of the need for a physician’s approval for my participation in exercise activities, programs, and use of exercise equipment. I acknowledge that I have either been given my physician’s approval to exercise or that I have decided to participate in exercise activities without the approval of my physician and do hereby assume all responsibility for my participation in these activities, programs, and use of any equipment.

Health History

Indicate any recent or past areas of pain, discomfort, health issue, or disease:

Have you previously seen a physical therapist or are you currently in physical therapy?

Previous or Current Chiropractic Care

Exercise History

How frequently have you been exercising in the last four months? What type of exercise? (ex: cardio, strength, CrossFit, classes, boot camp, etc.)

Approximate date of last exercise session:

What is/are your biggest challenge(s) with exercise?

Nutrition History

How often do you eat out?

How many servings of nutrient-rich food do you eat daily?

What diets or nutritional strategies have you tried in the past and for how long? Ex: low-fat, low-carb, high-protein, weight-watchers, food-tracking, meal delivery, Paleo, ketogenic, vegan, vegetarian, etc.

Sleep and Recovery

How many hours of sleep you get a night?

Do you use any other restorative strategies? (Ex: meditation, massage, acupuncture, hot tub/baths, etc.)

Health, Fitness, and Performance Goals

What do you want to accomplish through exercise? Ex: lifestyle change, physical ability, function, physique, weight loss/body composition, stress-relief, heart-health, consistency, strength, performance, sport- specific training, etc.

Are you training for a specific event?

What is your session availability?

Any additional comments?